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ANTISEPTIC SURGERY. 

THE PRINCIPLES, MODES OF APPLICATION, 
AND RESULTS OF 

THE LISTER DRESSING. 



w/ BY 

DR. JUST LUCAS-CHAMPIONNIERE, 

SURGEON TO THE HuPITAL TENON, MEMBER OF THE SOCIETE DE CHIRURGIE, 
EDITOR OF THE JOURNAL DE MEDICINE ET DE CHIRURGIE PRATIQUES. 



TRANSLATED FROM THE SECOND AND COMPLETELY REVISED EDITION, WITH 
THE SPECIAL SANCTION OF THE AUTHOR, 

AND EDITED BY 

FREDERIC HENRY GERRISH, A.M., M.D., 

SURGEON TO THE MAINE GENERAL HOSPITAL, 

PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS IN 

BOWDOIN COLLEGE, ETC. 



APR 30 181 



PORTLAND: 
LORING, SHORT, AND HARMON. 

1881. 



-^ 



Copyright, 1881, 
By Frederic Henry Gerrish. 



University Press: 
John Wilson and Son, Cambridge. 



TRANSLATOR'S PREFACE. 



Although for more than a decade it has been hardly pos- 
sible to glance through a medical journal without seeing 
something concerning the Lister method, there are compara- 
tively few medical men in this country who have a sufficiently 
good knowledge of this modern system of treating wounds 
to enable them to apply it with essential accuracy. The 
result is that it is either not used at all by most surgeons, 
or else is incorrectly employed with disappointing results, 
which are not fairly attributable to the method. This con- 
dition of affairs is probably largely due to the fact that there 
has been no low-priced treatise on the subject in the English 
language, from which one could acquire the necessary infor- 
mation with regard to the principles, practice, and results of 
Antiseptic Surgery. With the desire of supplying my fellow 
practitioners in America with such a work, and thus enabling 
them to experience the benefits of a method which will do 
more than any other to lead their surgical patients to re- 
covery without delay, danger, or discomfort, I have translated 
this work of an eminent French surgeon. Its careful perusal 
will, I believe, make it plain, not only that the Listerian 
theory is rational and its practice wonderfully satisfactory, 
but also that its application is neither difficult, nor seriously 
expensive. 

1 



Z PKEFACE. 

The book is so nearly exhaustive that there has seemed to 
rne to be need of very little editorial work. A few omissions 
of an unimportant character have been made, among them 
that of the bibliographical index, which is confessedly far 
from complete, and is quite unnecessary to those who have 
access to the published volume of the Index Catalogue of the 
library of the Surgeon-General's office, U.S. Army. In the 
chapter on apparatus, I have omitted the descriptions and 
pictures of several foreign spray -producers, and have intro- 
duced cuts of others which are made in this country, and can, 
therefore, be obtained more easily and cheaply than those of 
exotic origin. For the convenience of any who are not 
familiar with the metric system, a table of equivalents has 
been inserted near the end of the book. 

In a recent letter the author enclosed to me a report 
of four cases of Porro's operation, and it is so important 
and interesting that I have included it in the nineteenth 
chapter. 

My own additions to the work will be found in the foot- 
notes. 

F. H. G. 

Portland, Maine, 

4th of July, 1881. 



TO 



JOSEJPH LISTEE, 



PROFESSOR OF CLINICAL SURGERY IN KING S COLLEGE HOSPITAL. 



I dedicate the Second Edition of this Work to you, in the hope 
that it may have the same good fortune as the First. 

The purpose of the First was particularly to make known the 
principles and the method. It succeeded beyond my hopes. To-day 
Antiseptic Surgery is known in France. 

This new edition, much more comprehensive, and written with a 
much larger personal experience, is designed to teach more completely 
the practice, and how the resources of the method may be best employed. 
I trust that it will enable all its readers to appreciate the great 
progress which surgery owes to you. 



C N T E N T S. 



PAGE 

Introduction 9 

CHAPTER I. 

Progress of Surgery. — Practices designed to defend Wounds from 
the Injurious Action of the Air. — Occlusion and Antisepsis in 
Ancient and Modern Times. — The Method of Lister .... 17 

CHAPTER II. 

Theoretical Views on which the Practice of the Dressing is based . 25 

CHAPTER III. 
The Practice of the Dressing 33 

CHAPTER IV. 

The Dressing of Old Wounds which have, or have not, Fistules. — 

Wounds in the Neighborhood of Natural Openings 53 

CHAPTER V. 

Boracic Acid Dressing. — Unirritating Dressings. — Ununited Wounds 58 

CHAPTER VI. 

The Time when the Antiseptic Dressing may be omitted .... 60 

CHAPTER VII. 
The Suture and Closure of Wounds. — Superficial and Deep Su- 
tures. — Compression with Carbolized Sponge 62 

CHAPTER VIII. 
Drainage 67 



CONTENTS. 



CHAPTER IX. 

PAGE 

The Antiseptic Spray 73 

CHAPTER X. 

Catgut : its Uses as a Ligature, for Drainage, as a Suture, and in 

the Plugging of Bony Cavities 83 

CHAPTER XI. 

Influence of the Method upon the Phenomena of Repair. — The Ab- 
sence of Suppuration. — The Beginnings of Experimentation. — 
Absence of Micro-organisms 89 

CHAPTER XII. 

General Results of the Dressings. — Wound Complications. — Some 

Figures. — Lister. — Saxtorph. — Volkmann 104 

CHAPTER XIII. 

Particular Operations and Dressings. — Practice and Results. — Im- 
mediate Union. — Plastic Operations. — Extirpation of Tumors 
of the Soft Parts 115 

CHAPTER XIV. 

Compound Fractures. — Purification. — Immobilization. — Gunshot 

Wounds in Military Surgery 119 

CHAPTER XV. 

Osteotomy. — Rachitic Curvatures and Genu Valgum. — Fractures 

of Joints. — Resection in False Joints 124 

CHAPTER XVI. 
Amputations and Disarticulations 128 

CHAPTER XVII. 

Accidental and Operation Wounds of Joints. — Removal of Foreign 
Bodies. — Operations for Fractures and Dislocations. — Opening 
of Joints for Hydrarthrosis. — Opening of Diseased Joints. — 
Opening of White Swellings. — Antiseptic Irrigation of In- 
flamed Articulations 132 



CONTENTS. 7 



CHAPTER XVIII. 

PAGE 

Resection of Joints 143 

CHAPTER XIX. 

Operations upon the Peritoneum. — Strangulated Hernia. — Radical 
Cure of Hernia. — Umbilical Hernia. — Laparotomy. — Ova- 
riotomy. — Porro's Operation. — Cysts of the Liver . . . .146 

CHAPTER XX. 

Operations on the Female Genital Organs. — Operations with Perfect 
and Partial Asepsis. — Obliteration of the Vagina. — Vesico- 
vaginal Fistulas and Perineorrhaphy. — Enucleation of Fibrous 
Tumors of the Womb. — Aseptic Parturition 164 

CHAPTER XXI. 
Ligature of Arteries and Veins. — Radical Cure of Varices and Vari- 
cocele 176 

CHAPTER XXII. 
Treatment of Abscesses 180 

CHAPTER XXIII. 
Empyema. — Hypogastric Lithotomy 185 

CHAPTER XXIV. 

Castration and Operations on the Testicle. — Cure of Hydrocele by 

Volkmann's Method 187 

CHAPTER XXV. 

Operations upon Tendons and their Sheaths. — Opening of Large 

Cysts. — Club-foot. — Suture of Tendons 189 

CHAPTER XXVI. 
Trephining of the Skull 190 

CHAPTER XXVII. 

Treatment of Ulcers. — Epidermic Grafting 191 



8 CONTENTS. 

CHAPTER XXVIII. 

PAGE 

Ophthalmic Surgery 194 

CHAPTER XXIX. 

Influence of Listerism upon the Healthfulness of Hospitals . . .197 

CHAPTER XXX. 
Poisoning by Carbolic Acid. — Carbolic Eczema 200 

CHAPTER XXXI. 
Objections to the Antiseptic Method 204 

CHAPTER XXXII. 
Employment of Various Proceedings when the Elements of the 

Antiseptic Method fail .212 

CHAPTER XXXIII. 
Formulae for preparing the Materials employed in the True Lister 

Dressing 214 



APPENDIX. 

Comparison of some of the principal Measures of the Metric Sys- 
tem with those in common use. — Comparison of Thermometric 
Scales 230 

Index 233 



ANTISEPTIC SURGERY 



INTRODUCTION. 

The first edition of this book was published not long ago, 
and now the progress of the antiseptic method is so well 
known that there is no need of long preliminaries to tell how 
profoundly it has modified, even transformed, the surgical 
practice of our time. 

The reception with which it has met has undoubtedly 
varied: even in England it has difficulty in acquiring the 
position which is its due ; in Denmark it reigns supreme ; 
in Germany it has its enthusiasts, since it has undergone 
changes ; in Austria, Switzerland, Holland, Russia, Italy, and 
America, we meet eminent representatives of Listerian sur- 
gery ; and, indeed, we believe there is hardly a country 
where there are not some ardent disciples who proclaim its 
merits. 

In France it has gained a firm foothold, and, although we 
have had some difficulty in acclimating it in the hospitals of 
Paris, the situation is such to-day that there is small possi- 
bility of its being deposed. 



10 ANTISEPTIC SURGERY. 

In 1875, when, in my hospital service, I myself provided 
the materials for the dressing and the necessary apparatus, 
and undertook to make the first rigorously precise appli- 
cation, in accordance with what I had learned in Scotland, 
it met with a discouraging reception from many of my col- 
leagues. 

But I had followed the first steps of the method since 
1867; had seen it applied in Glasgow in 1868; had described 
it to the French surgeons in January, 1869 ; had kept it 
before them in every succeeding year by showing its progress 
and by introducing into my practice, with great success, the 
employment of powerful antiseptics. Above all, in 1875, I 
made at Edinburgh, de visu, an exhaustive study of it. So 
nothing could discourage me or deter me from faithfully 
testing it. 

Soon some of my colleagues, struck by the remarkable 
cases which I described to them, and surprised by the grow- 
ing reputation of the method abroad, asked me to teach them 
the practice of it ; and Professors Guyon and Verneuil were 
the first to be convinced by their own experience of its 
immense value. 

It was with difficulty that, even after a year of effort, of 
personal trouble, we prevailed upon the administration of the 
hospitals to furnish the materials for the dressing. To-day 
they can be had for the asking. 

This great step having been taken, there was a chance for 
the propagation of the Lister method ; and I was able to 
introduce it into the services of my colleagues and friends, 
and those of which I had charge, where it reigns supreme 
to-day. 

In fact, for four years I have had a large personal experi- 



INTRODUCTION. 11 

ence with the method, and that, too, in varied services, in 
widely different hospitals, in some of which I found the most 
deplorable sanitary condition. 

Now, what was this experience ? One could tell it in a 
word : in the Paris hospitals, and in the worst of them, we 
are obliged to make the most dreaded operations ; we per- 
form them with the same sense of security which we should 
feel in the country where the air is the most pure. We have 
thus all the outside advantages of the country, and all the 
facilities which can be furnished only in a hospital. 

Nelaton, who was esteemed one of the most fortunate of 
operators, was accustomed to say that the man who should 
discover the means of suppressing purulent infection de- 
served a statue of gold. If this view of Nelaton's was gen- 
erally entertained, the statue would be raised to Professor 
Lister ; for purulent infection has disappeared from the list 
of wound complications in the services where his method is 
followed. 

Erysipelas, if not altogether unknown, is infinitely rare. 
For four years, I have not had a single case after my opera- 
tions ; and yet I can truly say that, during that time, I have 
made all the operations which are most liable to be followed 
by this disease and purulent infection. 

But this is not all: security against accidents of this nature 
is, indeed, the chief advantage of the method, but the others 
are of great value. 

The wonderful regularity of repair and the rapidity of 
healing are two phenomena of the highest importance. Ask 
a patient who has suffered amputation of the leg whether he 
prefers to recover in twenty days rather than in two months ; 
ask a woman whose breast has been removed if she would 



12 ANTISEPTIC SURGERY. 

like better to be cured after one or two weeks, or remain 
from six weeks to three months with a gaping wound, — and 
you will have the response which some surgeons are obsti- 
nately bent upon not giving. 

These facts are not exceptional ; they are the regular and 
constant results of this method of procedure, of which we 
may say further that the subsequent suffering and the trau- 
matic fever are reduced to the minimum. 

The wounds unite immediately in the greater part of their 
extent, and the remainder does not suppurate. 

All the dressings are remarkably neat, are required less 
and less frequently as a case progresses, and we see disap- 
pearing from surgery the epithems, the uncleanness of which 
can only be compared with that of the pus-covered wounds 
which they were designed to protect. 

The results of this new surgery are so remarkable that 
they have attracted the attention of the most incredulous. 
These, as is well understood, will not allow themselves to 
apply the Lister dressing, but each borrows something from 
it, — perfect apposition, drainage, but, above all, the use 
of powerful antiseptics. Everything is laid under contribu- 
tion ; and we see to-day, in all the services in Paris, washing 
of hands, of instruments, and of patients in carbolized water, 
— a proceeding formerly unknown. 

This kind of thing is not the dressing of Lister ; and yet, 
such is the value of the principal directions so clearly laid 
down by him, that the results of the surgery of all these 
imitators are already vastly improved. 

As always happens in such cases, it has been contended 
that Professor Lister did not invent his own dressing; he has 
been accused of having pretended to discover antiseptics ; 



INTRODUCTION. 13 

and there are even those who deny the immense progress 
which has come from ascertaining the effects of necessary 
doses of these antiseptics. 

Have we not seen a comparison instituted between the 
dressing of Lister and that of Azam, of Bordeaux? Is it 
possible to compare the dressing of Azam, which is substan- 
tially only the partial apposition in the stumps after amputa- 
tion, together with drainage (an affair already known), with 
a method like that under consideration, which at once in- 
flamed the surgical world ? It is well to remember, too, 
that all publication upon the Azam dressing was subsequent 
to the announcement of the Lister method, and, better still, 
that Azam has never laid claim to it at all. With the great- 
est frankness, in publishing the very remarkable results of 
his practice, he made known the names of the surgeons who 
brought to Bordeaux the elements of the amputation dress- 
ing : Labat, the deep drain ; Dudon, the double suture ; 
Denuce*, the perfecting of the superficial suture ; and, more- 
over, each of these elements existed before this dressing. 

Doubtless the cause of these quarrels is that the surgical 
world still considers the dressing of Lister as a procedure, 
instead of comprehending the fact that it is a method. 
Any one who has attentively studied or experimented could 
not make a mistake upon this point. Whoever has followed 
a service where the antiseptic method is rigorously carried 
out must have been struck by the fundamental difference in 
the mode of repair of wounds. It is no longer a question of 
the more or less perfect healing after a particular operation ; 
but all surgery is affected. 

When one has seen wounds heal without suppuration ; 
abscesses, as soon as evacuated, dry up and close rapidly ; the 



14 ANTISEPTIC SURGERY. 

great joints, when opened, allow themselves to be roughly 
handled without resenting it ; clots of blood, instead of inter- 
fering with repair, contribute to its perfection, — he compre- 
hends that a new element has entered into surgery. It is 
not a question of comparing one dressing with others, of 
making a distinction between various topics. It is neces- 
sary to find out by experience whether the advocates of the 
method have stated facts, or have allowed themselves to be 
lured away by the promise of novelty. 

When we hear it said that this method is a matter of 
interest only in the great cities, in centres of infection, we 
regret that it is not better understood. Doubtless it is in 
the hospital, and the very worst, that it attains the highest 
degree of interest ; for it succeeds, in a way, in making the 
place healthy. But much more than this: it has so trans- 
formed surgery that its employment is called for every- 
where. Perchance, in exceptionally favorable conditions, 
one may omit some parts of the dressing which are indis- 
pensable in bad surroundings ; but the ensemble of the 
method must remain, and is demanded in the country as well 
as in town. Certain operations are justifiable only under its 
protection. 

Whatever has been the progress of modern surgery, the 
antiseptic method came at a time when the surgeon, often 
disarmed by surgical complications, saw his horizon limited 
by cruel uncertainties. It was impossible to predict the 
results of operation, and security was so imperilled that cer- 
tain conditions appalled the boldest, and certain operations 
were practically prohibited to the surgeons of cities, who, 
even though consummately skilful, found themselves unable 
to produce results equal to those of their far from expert 



INTRODUCTION. 15 

brethren in the country, where the atmosphere is untainted. 
The antiseptic method came, and gave an impetus to surgery, 
for it provided skill with means of success. 

This new power of surgery, it seems to me, can be acquired 
only by faithful disciples, as I shall explain further on. 
Approximations to antiseptic surgery, and attempts at 
imitating it, have everywhere ended in cruel disappoint- 
ment. 

Therefore, I have refrained from explaining in this work 
the modifications of the method which have been suggested, 
although I have studied them and know that some of them 
are of interest. Contrary to what has been said, I believe 
this surgery to be within the reach of all the world; I believe 
that every one may be so convinced that he will not deviate 
from the rules which have been laid down. But one can 
easily understand that, until it is acknowledged as a matter 
of surgical duty, only a small number will rigorously follow 
the necessary practice and attain satisfactory results. 

For my part, I write the new edition of this work to-day 
with a very different personal experience from that of four 
years ago. Whatever I state, I have tried and observed. I 
have educated myself upon all these points, and, confident of 
success, I have fearlessly performed operations which for- 
merly one would scarcely have ventured on. 

I assert more emphatically than ever that we can do no 
better than to remain faithful to the words of the master ; 
and that I may deserve to be considered elsewhere, as I am 
already in the Surgical Society, his apostle, I promise those 
who shall obey them the following things : — 

The disappearance of wound accidents even in the worst 
circumstances. 



16 ANTISEPTIC SURGERY. 

A regularity in repair hitherto unknown. 
Surgery without suppuration. 

Union by first intention habitually and without danger. 
Such rapidity in healing as to surpass all anticipation. 
The possibility and safety of operations hitherto considered 
dangerous and even unjustifiable. 

This is no vain promise, for these results are obtained 
daily, and we may be allowed to say with satisfaction that 
our efforts are crowned with success. A few years ago the 
hospitals of Paris were reckoned among the worst, even by 
the verdict of some of their own surgeons. To-day their 
surgery is as fortunate as that anywhere in the world. Even 
the Caasarean operation is successful. 



CHAPTER I. 

Progress of Surgery. — Practices designed to protect Wounds 
from the Injurious Action of the Air ; Occlusion and Anti- 
sepsis in Ancient and Modern Times. — The Method of 
Lister. 

Hardly any advance has been made in natural science with- 
out its having been remarked that discoveries of the same 
kind preceded the announcement of the modern achieve- 
ments. This is explained by the fact that in the sciences 
which depend upon observation, the conditions of experimen- 
tation are so complex, so disturbed by circumstances of every 
kind, that one cannot know at once all the elements of 
progress. He must advance when he catches sight of the 
truth, retrace his steps when certain circumstances conceal 
it from him, then advance again and take a longer and surer 
step, because all previous experience is pointing out the way 
to him. 

The antiseptic method followed the usual course : it did 
not come complete from the brain of one man ; it would be 
incorrect to say that it burst suddenly upon surgery like a 
revelation. The eminent savant who has formulated with 
so much care the minutest directions concerning it does not 
deny this, nor does any one of his devoted followers. 

If we go back to the earliest history of surgery, we find 
the idea of the harmful effect of the admission of air to 
solutions of continuity in the human body. In studying the 
history of surgery, we are continually catching sight of the 
constant struggle of art with this action, — an empirical 



18 ANTISEPTIC SUEGEEY. 

struggle, now abandoned, now renewed with ever increasing 
success. 

Two principal processes have constituted the elements of 
this struggle, — the occlusion of wounds, and antisepsis, which 
we venture to believe was unconscious. 

Occlusion is, theoretically, the simplest method of protect- 
ing wounds from the action of the air; practically, it is the 
most complicated. We find the beginning of its history 
among savages who cover their wounds with sand or mud, 
and think that their recovery is facilitated by this process. 

Two dates, celebrated in the history of occlusion, ought to 
be especially marked by two names, Magatus and Larrey. 
Magatus in 1616 not only briefly formulated the directions 
for occlusion, but wrote an account, marvellous for the age, 
of the theories of traumatic fever and of septicaemia. 

Larrey, with his great military experience, afterwards 
introduced a valuable method which contrasted with the 
recognized practice, and shocked the ideas of his contempo- 
raries, but saved many lives. In employing infrequent dress- 
ings, he acted empirically, guided by his wonderful clinical 
instinct. In spite of his natural desire to inspect the 
wounds, in spite of the dreadful odor emitted by the pus- 
saturated dressings, he persisted in his practice and obtained 
remarkable results. In analyzing these results, we find 
points which are difficult to explain ; yet we have a begin- 
ning of the interpretation in the science of the infinitely 
little. 

In our modern surgery we find a multitude of occlusion 
processes. Each of these has been thought to deserve the 
name of a new method, according as it was more or less 
complicated, more or less ingenious. In all of these methods 
there was a common principle, which explains their success : 
they prevented the circulation and stagnation of air in and 



OCCLUSION PROCESSES. 19 

about the wounds, perhaps simply by isolation, perhaps by 
exhaustion of the air and the altered fluids. 

Serious difficulties of application prevented the continuance 
of these methods, excepting the wadded dressing of Alphonse 
Guerin, which has rendered services so remarkable, although 
this eminent surgeon made it known only a few years ago 
(1871). This does not exclude the air, as the occlusion 
dressings pretended to do, but filters it, and consequently 
renders it harmless to the wounded organism. It fulfils yet 
other conditions, which are of less importance but advanta- 
geous to wounds, and constitutes one of the most powerful 
methods in surgery. We hasten to add that it is no longer 
an empirical dressing, but is based upon a serious scientific 
theory of the accidents of wounds, and is now always com- 
bined with antiseptic precautions. 

Ancient empiricism combated the harmful action of the 
air by proceedings much more powerful than the occlusion of 
wounds. There seems to have been a constant effort to 
change the injured surfaces, so as to avoid the immediate 
results of the fermentation and putrefaction of dead parts 
and organic fluids. The instruments by which the modifica- 
tion was produced were various : the actual cautery, boil- 
ing liquids, above all, antiseptic substances have played the 
chief part in the treatment of wounds. 

Modern surgery has erred in not holding in greater esteem 
the prescriptions of the ancients, and in not admitting that so 
remarkable observers could not have acted without discern- 
ment, and without depending upon the mighty facts of 
experience. 

What do we see, in glancing through the surgical phar- 
macopoeia, if not the constant employment of powerful anti- 
septic substances ? Undoubtedly, man does not correctly 
interpret his own actions ; undoubtedly, superstitious prac- 



20 ANTISEPTIC SURGERY. 

tices induce surgeons to put together substances which are 
more or less extraordinary, such as serpents, earthworms, 
and human fat. But, although in his opinion the effect of 
these substances is largely due to their supernatural power, 
he takes good care not to use them alone ; he always unites 
them with antiseptics. 

These are manufactured products, such as turpentine, wine, 
brandy, alum, common salt, etc., and many vegetable sub- 
stances, among which we find aloes, the leaves and shell of 
the walnut, figs, and many other substances quite as valuable. 

Cataplasms even are of infinite variety, and contain antisep- 
tic, aromatic, and other substances. It is only in our time 
that a panacea has been found in linseed pulp, a fetid topic 
and natural receptacle of all injurious organisms. 

Surgeons do not even neglect the atmosphere, for they 
advise the employment of aromatic substances, and disin- 
fectants suitable for the fumigation of the sick-chamber. 

The most ridiculous and mysterious of their formulas, after 
all, depend only for their activity on antiseptics, often com- 
bined with oily substances which serve as vehicles and to 
isolate the wounds. 

The famous oil of puppies, the secret of which cost Am- 
broise Pare two years of entreaty, was only a mixture of oil, 
brandy, and turpentine, in which living puppies and earth- 
worms played the necessary role of mystery. 

The commander's balsam, an alcoholic compound of ben- 
zoin, is a type of the antiseptic substances, and its employ- 
ment has recently been recommended anew. 

At a more modern date, and in the most classic works, we 
also find prescriptions as neat as this of Dionis : " Oily and 
putrid remedies are of no use in wounds of the head ; the 
balsams and spirits are there of the most advantage, for 
which one ought to keep white balm and spirit of wine." 



UNCONSCIOUS ANTISEPSIS. 21 

If we go from medical works to the histories of chivalry, in 
which there is no lack of recipes for infallible balms, we again 
find the employment of antiseptics. 

Since the confidence inspired by these substances has con- 
tinued for ages, it is probable that they have some real action, 
that their reputation is partly deserved, and it is surprising 
that surgery should all at once have the vanity to say, " Our 
fathers were entirely mistaken ; " and henceforth surgery is 
done with lint, cerate, linseed-meal poultices, and hot and 
cold water. 

Is it necessary to attribute this abrupt change largely to 
the influence of physiologism, to the doctrine of inflamma- 
tion, to the work of men whom Velpeau called antiphlogis- 
tiqueurs, even while he was constantly under their influence ? 

However it may be, the reaction has come about, and is to 
be explained first and foremost by an empirical return to anti- 
septics. A great number of substances of recent production 
have been extolled, and everybody has been able with reason 
to praise the favorable influence of a new dressing. Carbolic 
acid, an entirely modern production, has been recommended 
by many. We have seen several surgeons employ carbolic- 
acid dressings, freely using weak solutions of it, and also, 
what is still more important, sprinkling carbolized water 
about for the purpose of counteracting the poison of wounds. 
By these means the wounds heal more rapidly, and the 
healthfulness of the wards is improved. 

But alcohol has attracted the most attention. Ardently 
advocated by Bataille and Le Cceur, this dressing had the 
good fortune to be adopted by Nelaton. Bataille' saw in it 
the final suppression of purulent infection. Le Cceur, with 
his dressing, actually returned to the ancient practice, recom- 
mending with the alcohol much neglected articles. 

This dressing had an advantage over others in being based. 



22 ANTISEPTIC SURGERY. 

upon a theory which was revived by Neudorfer some years 
afterwards for carbolic acid. Alcohol coagulates albuminoid 
substances, and makes them imputrescible ; it contracts the 
minute blood-vessels, and renders them incapable of absorp- 
tion. 

Whatever there may be defensible in this explanation, 
there has been rapid progress in this modern period. All 
antiseptics, from pure alcohol to dilute caustics, have been 
employed with varying success, but always with success. 

We have seen, then, substances which were formerly 
thought to be irritant come into ordinary surgical use, 
hastening and insuring the healing of wounds instead of 
retarding it. 

Doubtless the action of each dressing was capable of an 
explanation, but sufficient evidence was not adduced to estab- 
lish it. It was thought that some modified the wound, that 
others acted upon the secretions, that others afforded protec- 
tion from the action of the air. It was easy to see that great 
progress had been made, for surgery was already much im- 
proved ; but it was difficult to give the reason. 

Furthermore, success, though actual, was far from being 
constant. Although accidents were less frequent and the 
progress of repair was more regular, still with the failures 
astonishing discrepancies were observed, which the theories 
previously advanced did not explain. 

Antiseptic surgery, with its constant achievements and its 
scientific interpretations, begins a new period, marks an 
important triumph. The regularity of the work of repair, 
almost without regard to tissues and media, bringing all 
points of the economy under a common law, is what chiefly 
attracts the attention of the observer. 

The method which Professor Lister has taught since 1866 
is evidently connected with the great progress which we 
record. 



THE LISTER METHOD. 23 

This surgeon protects the organism against the hurtful 
action of the air, at least against those parts of it which are 
poisonous. 

He gives the theory of the action of antiseptics. 

He directs and assures the regular course of repair. 

He imparts to the organic elements their greatest possible 
reparative power, by removing everything which he had ascer- 
tained to be obstructive to their functions of renewal. 

Physiological study, we may say, of the healing wound 
agrees with the theoretical ideas which he has advanced as 
necessary conditions. In my opinion, this will be the true 
criterion of the value of the method, and of the importance of 
the discoveries to which it will give birth. 

The method of Lister is an immediate result of the dis- 
coveries of Pasteur. This eminent savant explained the 
cause of the injuriousness of the air. He showed that fermen- 
tation is impossible in pure air. But at the same time he 
demonstrated that everywhere air is impure ; that it is sur- 
charged with germs in densely populated localities ; that the 
number of germs is less in country places ; and that when we 
come to the summits of high mountains the scarcity of germs 
is remarkable, but still there are germs. 

Now, according to Lister, as we shall see later, it is not the 
air itself which is hurtful to wounds, but the germs in the air 
are the source of their putrefaction and infection, and the 
cause of accidents. 

It is still very difficult to explain the exact mechanism of 
these accidents. But the researches of Pasteur and his 
pupils, of Davaine, of Lister, of Bert, of Tyndall, have 
awakened the study of the evolution of germs in infectious 
maladies, septicaemia, pyasmia, and even puerperal fever. 
The pursuit of the micro-organisms, to use Sedillot's happy 
expression, is made every day, and every day we study 



24 ANTISEPTIC SURGERY. 

more accurately the conditions of their existence and re- 
sistance. 

We are beginning to understand that, in the microcosm of 
the vibrios, all the beings are not equally baleful ; how it is 
that the appearance of certain of them coincides with the dis- 
appearance of certain others ; how the presence of fresh air, 
frequently renewed upon a denuded surface, is less favorable 
to their development than a dressing which imperfectly covers 
a wound. 

We have seen that certain substances, employed as topics 
and called antiseptics, arrest the evolution and the multipli- 
cation of these germs. 

We already explain the apparent inconsistencies of the 
theory and the practice. We know how dressings as different 
as the wadded, the antiseptic, and even the open dressing act 
in the same direction ; it is by the total or partial destruction 
or sterilization of micro-organisms. And although the germ 
theory leaves so many points to be studied, so many obscuri- 
ties to be lighted up, it certainly draws a decided confirma- 
tion from the practices and theories of modern surgery. 

Science advances ; till now we have destroyed the germ 
without seeing it, almost without knowing it. Thanks to 
modern observers, we have caught the vibrio in the process of 
evolution ; we study it, and every day new proofs are added 
to the experiences upon which are based the theory of 
the harmfulness of the air and the practice of antiseptic 
surgery. 



CHAPTER II. 

Theoretical Views on which the Practice of the Dressing 

is BASED. 

The antiseptic method is founded upon a certain number of 
theoretical ideas, of which the first and most important is that 
of the existence of germs. 

It was in hospital practice, among the perpetual failures of 
surgery in a thoroughly infected hospital (Glasgow), that 
Lister conceived the idea of the method which has made him 
so famous. He had struggled ceaselessly and in every 
possible way with insalubrity, and was constantly vanquished 
by its fatal influences. 

Persuaded that the atmosphere about the wounded is 
especially pernicious in its effects, he thought that these 
should be attributed to the numerous germs which Pasteur 
was studying in all the media which surround us. He be- 
came a convert to the doctrines of the eminent French 
chemist. This was in 1865, — that is, a short time after the 
first publications of that illustrious experimenter. Lister 
made for himself numerous experiments which demonstrated 
the presence of germs in the atmosphere, and their influence 
upon fermentation and putrefaction, and then proposed to 
enter into a struggle with the disturbing elements. The 
atmospheric germs, he said, provoke suppuration ; they ex- 
cite putrefaction of the blood and other animal fluids, and, 
by this process, produce complications in wounds. 

Thus the germs or microzymes are, according to him, the 
cause of the infectious accidents of wounds ; and, if they are 

3 



26 ANTISEPTIC SURGERY. 

destroyed, if their development is prevented, we shall be 
guarded against the complications which harass surgery. 

The germs, like the vibrios which they engender, are infi- 
nitely varied : all are not equally harmful ; it is even certain 
that there are some which destroy those more harmful than 
themselves. But they exist always in the atmosphere, de- 
posited upon the surface of all objects, and especially in all 
putrefied and putrescible matters which remain on the instru- 
ments, the hands, and the pieces of dressing. 

It being impossible to discriminate between the good and 
the bad, the surgeon should seek the suppression of all. The 
direct or indirect destruction of all these living beings and of 
all germs has been practised by Lister. 

The result has been the disappearance of the accidents of 
wounds ; he has seen purulent infection and hospital gangrene 
absolutely put to flight. Hospitalism is no longer a cause of 
mortality. 

The ensemble of conditions practically necessary to the dis- 
appearance of the germs put the wounds into a peculiar state, 
and little by little Lister was led to study exhaustively the 
conditions of their repair. He very soon saw that to insure 
the healthiness of wounds not only must the micro-organisms 
be kept away, but it was also necessary to study certain con- 
ditions which are favorable, even essential, to the regularity 
of the reparative process, if one wished to achieve more per- 
fect surgical results. 

These conditions are subordinate in comparison with the 
prime importance which must attach to the destruction of 
germs, but yet they play a prominent part in practice. 

When the conditions are most favorable to the repair of 
tissues, as in subcutaneous injuries, there is no suppuration. 
Contrary to many of the received ideas, it must be admitted 
that suppuration is not a necessary phenomenon. It implies 



CAUSES OF SUPPURATION. 27 

a difficulty, an obstacle to repair. It appears when the vital 
ity of the newly formed elements is lowered. It is necessary 
to seek for the cause of the irritation which is produced, the 
source of the trouble. Lister recognized the fact that three 
conditions produce this untoward result : — 

Excessive tension in the tissues. 

Direct irritation of the living tissues, and the presence of a 
foreign body. 

Direct irritation by the atmosphere charged with germs. 

What is excessive tension ? It is the phenomenon accom- 
panying all local inflammations, liable to lead to suppuration. 
In a phlegmon, in a dropsy, in a considerable effusion of 
blood, there is excessive tension. 

Leave an abscess to itself in the process of formation, and 
you see this excessive tension develop and increase without 
cessation. Suppuration advances and continues even to the 
point of solution of continuity. Penetrate to the purulent 
layer, reach the abscess and evacuate it : it ceases to advance ; 
the tension disappears ; and one of the causes of suppuration 
is removed. Then the others show themselves ; but if you 
can arrest your disease at that point, you will see the suppu- 
ration dry up with remarkable rapidity. The opening of the 
abscess with the precautions of the antiseptic method serves 
to show the truth of this theoretical view. 

We have another distinct illustration in the accumulation 
of serum beneath flaps which have united by first intention. 
Close wounds hermetically and let liquid accumulate, and a 
focus of suppuration will be formed behind the flap. If the 
wound is in a region liable to infiltration, in the scalp, for 
instance, there is the starting point of an immense phlegmon. 
The retention of fluid may be the sole cause. Therefore the 
draining-off of superabundant fluids should always be pro- 



28 ANTISEPTIC SURGERY. 

moted by all possible means, and the method of Professor 
Lister pre-eminently fulfils this indication. 

Another disturbing cause of no less importance is direct 
irritation. Apply permanently to the surface of a wound an 
irritating or caustic substance, and you will see a purulent 
secretion form. Mortification, wholly superficial though it 
be, will induce the immediate throwing-off of the parts. 
Then, if the irritation continues, granulation takes place. 
The granulations being irritated give rise to suppuration. 

One can observe these facts easily. If we inject irritants 
into subcutaneous wounds, which, left to themselves, would 
not suppurate, they do suppurate on the principle of irrita- 
tion. If an external wound, although it be absolutely aseptic, 
absolutely secure against the contact of germs and atmos- 
pheric products, is dressed with an irritating substance, it 
necessarily suppurates. If the use of the irritant is continued, 
the wound becomes granular, the granulations suppurate. 
The granulation was no more a necessary phenomenon of 
repair than was the suppuration. 

The irritant substance may be a foreign body. Neverthe- 
less, if this foreign body has no direct irritant action upon the 
living parts, if it is absolutely aseptic, that is to say, unaccom- 
panied by germs, it can interfere in no wise with the phenom- 
ena of repair, and will permit normal action to go on all 
around it, of which we shall give examples when speaking of 
ligatures which are enclosed in wounds. 

We come now to the last condition, the basis, the chief 
point in the theoiy of suppuration, — the influence of germs. 
Let us imagine a wound without excess of tension, without 
local irritation, without a foreign body. If atmospheric germs 
are deposited upon this wound, it will suppurate. It is not 
the action of the air itself which induces this suppuration ; for, 
if we make the atmosphere strictly aseptic, entirely free from 
germs, the wound will not suppurate. 



PUTREFACTION FROM GERMS. 29 

Doubtless, the purer the air becomes, the less harmful is it 
to a wound ; but it must be perfectly deprived of germs 
before it can absolutely cease to be a cause of suppuration. 
The surgeon should be thoroughly convinced of the truth 
of the germ theory. As the eminent Edinburgh professor 
has picturesquely remarked, he ought to see germs in the 
atmosphere as one sees birds in the air. 

There is a great difference between this cause of suppura- 
tion and the others that we have mentioned. On this ac- 
count we should be very careful not to put them upon the 
same plane ; we should put forward the germ theory as the 
pivotal point of the antiseptic method. 

Germs have a double action : they do not simply excite 
the formation of pus, they induce putrefaction ; they deter- 
mine the putrefaction of animal fluids, and thus they are the 
agents of wound complications, especially of the most formi- 
dable, pygemia. 

There are great differences in the nature of the suppura- 
tion excited by the first causes mentioned, and that which 
results from the access of germs to wounds, which led Pro- 
fessor Lister to say, that in the last case, the wound is 
infected, that putrefaction has set in. 

In the first case, suppuration is localized at the defective 
point, at a point of suture, or at an angle of the wound. 
Sometimes the pus is pent up, sometimes a little viscid, 
usually not abundant. The pus corpuscles are granular, dis- 
torted. The dressing sometimes has a heavy odor, but it 
does not have that of putrefaction. 

If we suppress the cause, if we relieve pressure at the point 
where the fluids are retained, if we avoid the employment of 
an irritant, and order is restored, suppuration disappears. 
With it immediately disappear the febrile symptoms which 
accompanied it. The case of the retention of fluids is espe- 



30 ANTISEPTIC SURGERY. 

cially remarkable in this regard, — that the changing of a tube 
or the removal of a stitch is sufficient to modify both the general 
and the local state. I have been amazed at the appearance 
of a drop of concealed pus ; but this having been evacuated, 
order is completely restored. 

But if germs have had access, if the dressing is infected, 
the conditions are entirely different. The whole wound is 
affected, pus invades it, — common, laudable pus ; and the 
dressing which is bathed in it has acquired an offensive, 
putrid odor. Whatever we do now, suppuration will con- 
tinue, healing will be by granulation, and the rapid repara- 
tive process of the antiseptic method is lost. Almost all 
means will be of no avail to restore the wound to its original 
aseptic condition. I say almost all means, because we shall 
see further on that, by certain contrivances, we have come to 
employ the antiseptic method in the treatment of wounds 
which have suppurated, in fistulse, etc. Up to this point it 
has been my endeavor to indicate the progress of the phenom- 
ena and the theory which explains them in the case of a 
wound made by the surgeon, where the diseased part has been 
restored with unbroken skin. 

In all wounds which have been exposed to the air for some 
time there exist granulations, the favorite lairs of microscopic 
organisms in all stages of development. 

In order that these wounds may be put into the condition 
of fresh wounds, and rendered susceptible to the same modi- 
fying influences, their surfaces, their granulations, must be 
destroyed ; next, the cavities where they lie must be made 
healthy by means of powerful antiseptics ; and then, perhaps, 
it may be possible to treat them like fresh wounds, to cause 
tension and irritation to disappear, to prevent the further 
entrance of germs, and to allow the wounds to heal without 
granulation. 



ELEMENTS OF THE TREATMENT. 31 

If one will read over the principal elements in the treat- 
ment of wounds, he will at once comprehend them : — 

Destroy the germs or living organisms. Then use anti- 
septics of various strengths, according to the condition of 
the wounds. At first, it is prudent to have the antiseptic 
excessively strong. Then make the atmosphere antiseptic. 

At the points where the germs develop, where living beings 
are evolved, the strength of the antiseptic ought to be in- 
creased. If they are lodged in parts where there are sinu- 
osities, their destruction will be impossible. 

We know that certain conditions are particularly favorable 
to the evolution of germs, namely, moisture and the presence 
of putrescible matters, which are capable of furnishing pabu- 
lum for the fermentative process. These must be avoided. 
Pus and urine are favorite media for the evolution of germs. 
We should take good care not to let them accumulate, and 
in these cases should use the most powerful means. 

There are spots where germs develop very readily, and 
experience teaches us how to recognize them. In general 
the healthy organism is a less favorable ground for the evo- 
lution of germs than the diseased. 

Excess of tension is avoided by whatever insures the drain- 
ing-off of fluids. 

Direct irritation is avoided : — 

First, by apposition, which shields the organic elements 
from all untoward influences, and in some way immediately 
incorporates them in the organism. 

Second, by the exclusion of every foreign body which is 
septic. 

Third, by protecting the wounds from the direct and con- 
tinuous action of the antiseptics. 

I here make note of the apparent paradox that the tempo- 
rary action of an antiseptic, even if it is caustic, is not to be 



32 ANTISEPTIC SURGERY. 

considered as a cause of irritation sufficient to produce suppu- 
ration. The best proof of this is that the most powerful car- 
bolic solutions and the eight per cent, solution of chloride of 
zinc, which are genuine caustics, do not hinder the rapid 
union of the parts which they touch. 

If the theory is correct and the preceding conditions are 
fulfilled, the organic elements ought to preserve their maxi- 
mum of vitality. In wounds which are fairly sound, in open 
cavities, repair ought to take place at once without infectious 
accidents, and without suppuration, just as in subcutaneous 
injuries. In certain respects, and in certain particular cases, 
repair ought to be even more rapid than in some subcutaneous 
lesions, because there is no trouble from excess of tension, 
such as is liable to occur in the latter. 

Practice justifies the theory, as the following pages will 
prove. Perhaps the facts are capable of some other theoretic 
interpretation ; but no other could be as satisfactory. 



CHAPTER III. 
Practice of the Dressing. 

The method of Lister, as we see, is not founded upon a 
special dressing ; it has a complete theory with three princi- 
pal parts, which point to as many prescriptions of the highest 
importance. This method may be practised in very different 
ways, all conforming to these three indications ; it holds good 
always. It is also evident that the procedure of its author is 
capable of important modifications. To achieve his results, 
Lister himself developed his work by successive stages. He 
has made applications infinitely more complicated and less 
fortunate than those which he commends to-day; and for ten 
years, while professing the same beliefs, he has little by little 
simplified and rendered applicable the means which he has 
advocated. The employment of an antiseptic paste of chalk 
applied to wounds, the use of costly plasters to effect occlu- 
sion, metallic papers, carbolized oil, rapidity of dressing under 
compresses of carbolized oil or water, all these means have 
successively given him favorable results ; but he only truly 
achieved practical and complete results after he began to 
employ the antiseptic gauze and the carbolized spray in the 
atmosphere of operations and dressings. 

Therefore, seeing none but a historical interest in recalling 
the first attempts, I will give only the procedures which he 
constantly employs in his service. 



\ 



34 ANTISEPTIC SURGERY. 



I. — Destruction of germs and living organisms before the 

operation. 

As I have said before, the destruction of germs is the 
principal object to keep in view. This would be the only 
result sought by the method were it not for the accessory 
conditions which I have mentioned, and to which I shall 
return. 

Germs, which are met with everywhere in the atmosphere, 
are found all over the surface of bodies which are in it; there- 
fore, everything which must come in contact with a wound 
ought to be purified of germs, of living organisms deposited 
upon its surface. 

Certain things especially afford lodgment to these living 
organisms, such as sponges and the common objects on which 
putrescible matters are most likely to settle. 

All these articles should be prepared in such a manner as 
to make them perfectly innocuous, to deprive them of living 
beings and of germs ; and this result may be obtained by 
immersing them in a fermenticide bath. 

Two aqueous solutions play an important part in the dress- 
ing : a five per cent, solution of carbolic acid — the strong 
solution ; and a two-and-a-half per cent.! — the weak solution. 

The instruments are immersed for some time before the 
operation in the strong solution. It is well to rub their sur- 
face with a linen cloth or a sponge in order to moisten them 
in their entire extent and in all their crevices. 

The sponges are permanently kept in this strong solution. 
Before using them in the operation, they should be carefully 
wrung out. 

Every object, before it is allowed to touch the wound or 
its surroundings, should be purified in the same manner. 



DESTRUCTION OF GERMS. 35 

The field of operation, that is, the site of the operation, and 
the neighboring parts, should be carefully cleansed with a 
sponge saturated with the strong solution. 

Many precautions have been recommended for this prepar- 
ation of the field of operation, which do not seem to be indis- 
pensable. 

It has been recommended to soap the region with the 
greatest care, and to wash it with ether to remove absolutely 
all oily matter. It would be bad taste to deprecate this 
excess of neatness ; but since it has been objected to the 
method that it is too intricate, it is no more than fair to 
exclude useless complications. 

Now, Lister observed that the watery solution of carbolic 
acid is penetrating. It easily soaks into the layers of the 
epidermis, and we may be sure that, when the bathing with 
the strong solution has been done with sufficient care, the 
region is perfectly cleared of germs. This is the practice 
which I have seen followed in the Edinburgh Infirmary and 
in London by the professor, and the excellent results of 
which I have noted. In my turn I have followed it, and 
have nothing but praise for it. If the region is very dirty or 
greasy, one may, as a preliminary, wash it with hot water, 
which prepares it very well for the action of the carbolized 
solution. 

The action of the strong carbolized 'water is sufficient for 
the instruments ; the precaution of rubbing them is useful, 
because the water often runs off of their surfaces and their 
angles sometimes contain putrid matter. In the case of 
certain instruments which have irregular extremities, such as 
forceps, Lister thinks it well to dip them in carbolic oil, con- 
taining a tenth part of the acid. 

The hands of the operator and of his assistants, which will 
come in contact with the wound and the instruments, should 



36 ANTISEPTIC SURGERY. 

be purified in their turn, and every time that they are re- 
moved for any cause whatever from the carbolized atmos- 
phere in which the operation is being performed, they should 
be purified anew. For this purpose the strong, really caustic, 
solution is not necessary. It is sufficient to dip the hands 
into the weak solution. 

Such are the preparations, the necessary preliminaries of 
an antiseptic operation, and one can see that it practically 
amounts to little but attention to the minute details of clean- 
liness. And, for my part, long before I adopted the applica- 
tion of the antiseptic method, I pursued this course as often 
as possible, and never had occasion to regret it. The chiefs 
of the service and the students in our hospitals have often 
been charged with lack of neatness, for which they should 
not be blamed, in the actual condition of affairs. It is diffi- 
cult, in the present circumstances, for a chief of the service to 
wash his hands, but it is almost impossible for students. As 
it is in human nature to struggle as little as possible with 
difficulties, the result is bad. The employment of the anti- 
septic method changes all this, for even the nurses now have 
clean hands without trouble. 

What is said here of persons is equally applicable to the 
instruments, and I have come to be quite particular about 
their cleanliness as regards putrescible matters. We are 
insured against all danger when they are antiseptically neat. 
Even the most putrid sponges are purified with great facility, 
as one can easily observe. 

II. — Destruction of germs during the operation. 

Thus, all the precautions are taken, everything which is to 
touch the wound is aseptic, deprived of the elements of sep- 
ticity. But in the course of the operation the atmosphere 



THE SPRAY. 37 

will pour upon the wound, upon the operator, upon the in- 
struments, torrents of germs which could not be neutralized 
at the time. To prevent this, Lister at first sought to the 
best of his ability to protect the wound from the access of 
fresh air, operating behind a compress soaked in carbolized 
oil, and covering the wound as rapidly as possible. All this, 
however, seemed to him insufficient ; and at last he conceived 
the happy idea of creating around the wound an antiseptic 
atmosphere. The pulverization of the carbolized water in a 
powerful stream on the field of operation brought him abun- 
dant success. 

This manoeuvre, to which unjustifiable theoretic objections 
have been made, is extremely simple ; with any one of the 
pieces of apparatus which we shall study further on it can be 
made without trouble. It merely consists in enveloping 
the region of operation, the hands of the surgeon and of his 
assistants, in the spray furnished by a reservoir of carbolized 
water, thus creating a pure artificial atmosphere around the 
wound. 

This spray ought to be so fine as not to interfere with or 
wet the operator, and still be abundant. 

The apparatus requires a certain amount of attention. 
The assistant should be familiar with his work. He should 
not keep too near the wound, — a mistake which I have 
seen made. The liquid stream is not intended to have 
a local action on the wound. It should be so far removed 
that the field of operation may be enveloped in a cloud. 
Care should be taken to keep it aimed at the wound, not to 
send it into the face of the operator, and to accommodate it 
always to his changes of position, that an antiseptic atmos- 
phere may constantly be preserved. It is well to look out 
for the stream ; it is even necessary, in this respect, to mis- 
trust the steam apparatus, for it is not uncommon to see the 



38 ANTISEPTIC SURGERY. 

steam rush out without drawing up the antiseptic fluid, and 
thus the antiseptic action is lost. Drafts of air should be 
taken into account, as they displace the pulverized stream 
and may make it inoperative. These minutiae are somewhat 
difficult to observe, but are indispensable to the accomplish- 
ment of the antiseptic protection. Some surgeons have over- 
looked the causes of their lack of success, and have blamed 
the method, when really the fault was their own, in having 
failed to observe these precautions. 

If, from any cause, the spray fails, or if one wishes to give 
his assistant a rest during a dressing, it is easy to take a com- 
press, soak it in a weak solution, and with it cover for a 
little while the operating field and the neighboring parts. 

There is one direction which it is worth while to remember: 
irritation of the eyes of the patient by the spray should be 
avoided ; so, during the operation and the dressings, one 
should habitually cover the face with a napkin or a dry 
compress. 

No other special precautions during an operation need be 
mentioned. The sponges are wrung out in the weak solu- 
tion, but when the operation is over, the strong solution 
should be used for the bathing. This bathing gives the blood 
and muscles a gray or chocolate color, which is clear and 
characteristic. It is a capital precaution to take. 



III. — Defence against germs after the operation. 

When this is over, it is still necessary to maintain about 
the wound an antiseptic atmosphere, and this is the object of 
the antiseptic gauze, an essential element of the dressing. 

The wound should remain in a sort of sheath made by this 
gauze, which is of the consistency of common tarlatan. It 
is saturated with resin and paraffin, mixed with carbolic acid ; 



THE GAUZE. 39 

it gives up the carbolic acid, which is volatilized little by little, 
particularly in contact with warm bodies. By covering this 
gauze with an impervious cloth, the carbolized atmosphere is 
confined about the wound. Moreover, one is sure that the 
discharge from the wound will traverse the entire dressing 
before reaching fresh air. If it were otherwise, it would run 
directly through the gauze to the air. There it would be- 
come infected by the entrance of germs, and, if the passage 
was short, the infection would be propagated across the dress- 
ing, although it was antiseptic. 

From this arrangement a curious and easily observed phe- 
nomenon results. When one removes the dressings within a 
day or two, there is usually a good deal of discharge. If it 
happens, for example, to be in a member which rests on a 
cushion, this, being saturated with fluids, may emit a bad odor. 
We remove the dressing whence all this discharge has come : 
it contains more or less fluid ; its folds are stained and satu- 
rated, but no odor comes from it. 

We renew the dressing with the precaution of the spray, 
washing the wound with the strong solution first, afterwards 
with the weak, according to our apprehension of too great 
irritation of the wound. We are guided in renewing the 
dressing by the amount of discharge : at first, every day, if it 
is necessary ; then every other day, and afterwards less 
frequently. 

In this manner the conditions relating to germs are ful- 
filled. Though I have mentioned a good many minutiae, I 
insist that practically it is only necessary to establish the 
habit ; and I can assert that, from the beginning of the trial 
during my term of service at the hospital, my pupils, as well 
as myself, took all the antiseptic precautions, and that our 
dressings, in truth quite infrequent, occupied no more time 
than was consumed by other methods, always excepting the 
wadded dressing of Guerin. 



40 ANTISEPTIC SURGERY. 

Drainage of fluids ; 'precaution against excess of tension. 

As I have said above, the dressing ought to fulfil other in- 
dications. The first, and without doubt the most important, 
is that of drainage. The fluids ought always and from every 
point to have free vent. Lister always insures this condition, 
selecting his methods, and giving preference to those which 
make drainage easy. Then he immediately closes the wound, 
but leaves several small openings, in which he places drain- 
age-tubes. It may be said that Lister never uses a dressing 
without employing the tubes of Chassaignac, as he has the 
courtesy to call them, in honor of our eminent countryman ; 
but he uses them in a little different manner from that which 
is customary with us. He does not pass a loop from one 
point of the wound to another, but introduces a tube into the 
opening perpendicularly, — long enough to terminate just at 
the surface. At the outer extremity are fastened two threads 
designed to keep it in place and to draw it out by at each 
dressing. 

The tube should not be too long ; it should make a canal 
for easy drainage, but it ought not to strike against the soft 
parts to irritate them. To introduce it perpendicularly into 
the passages, which are often very long, Lister uses an instru- 
ment which he calls fistula-forceps. This is simply a dressing 
forceps, with very long and slender blades. If the tube is 
too long, he withdraws, shortens, and then replaces it. If 
it projects beyond the surface, it will be pressed upon by 
the dressing, and will irritate the deep parts, and this must 
be avoided. 

At each dressing the drainage-tubes are withdrawn and 
washed in a strong solution, to clear them of the blood and 
puriform matter which they may contain. Each time it is 
necessary to diminish their length, for the wound heals rapidty 



DRAINAGE. 41 

at the bottom, and seems to drive them out. After being 
shortened they are put back again. Tubes of smaller calibre 
should be substituted for these, if they are large, and gradu- 
ally a diminution in size should take place. 

When we see that the discharge has entirely ceased, the 
tube is withdrawn and the external wound closes up. It is 
always necessary to guard against too speedy withdrawal, 
for the fluids accumulate very rapidly and make abscesses. 

The employment of sufficiently large tubes is imperatively 
insisted on. Their walls should be very thick, else they col- 
lapse, and their capacity for drainage ceases. 

It is well to place them beforehand in a vessel of strong 
carbolized water ; the caoutchouc absorbs the carbolic acid 
well, and remains absolutely aseptic, is even somewhat 
antiseptic. 

There are other precautions necessary to insure drainage. 
Care must be taken with regard to the position of members, 
not to raise the stumps as much as is generally done. At 
each dressing we must make sure that the drainage works 
well, by pressing upon the lips of the wound. If the exist- 
ence of cids-de-sac is suspected, gentle pressure should be 
made with a sponge. If points of suture seem too tight, they 
should be cut ; if even at one of them there are manifest 
traces of inflammation, we must not hesitate to plunge in the 
point of a bistouri, give exit to the accumulated drops of pus, 
and put in a small drainage-tube. I have done it with 
success. 

Perhaps there may be a considerable failure of drainage, in 
which case, besides local tension, one observes a general feb- 
rile state. Removal of the constriction is necessary, and 
must be ample, even if one has to take some stitches after- 
wards to close the wound. Sometimes the drainage opening 
is large enough, and then one can profitably inject a little 

4 



42 ANTISEPTIC SURGERY. 

of the strong or the weak solution, according to the case, to 
wash out all putrescible matter. But this should be entirely 
exceptional. I once knew Lister, after having opened a knee 
for an old dropsy, to find fever the third day, and attribute 
it to the fact that the chance for drainage was not sufficient. 
He made a larger opening, and the fever abated. 

Precaution against irritation. 

Lister seeks for the most rapid union possible, so he always 
immediately sews up the lips of wounds. This suture is 
generally made with silver wire, and resembles all interrupted 
sutures ; but in addition he usually takes a deep suture of 
large silver wire, each extremity of which pierces and is then 
twisted around a plate of lead. 1 When this is tightened, it 
bears all the strain ; tension and swelling do not show them- 
selves even upon the lips of the wound, in which union is 
obtained more rapidly and firmly than without the deep 
stitch. 

Lister cuts the wires very early in order to avoid tension 
of the parts which they hold ; but, in order that these may 
not be altogether deprived of support, he often leaves the 
wires in place. 

There is one rule which it is useful to know : one need not 
be anxious about the blood which is poured out between the 
flaps. It is necessary to take great care not to evert a flap 
or displace a stitch for the purpose of removing a clot of 
blood ; for it will not hinder the phenomena of repair or 

1 The lead plates have applications outside the antiseptic method. 
Lister especially recommends them in the operation for hare*-lip, and I 
have employed in this case four plates to hold the deep sutures. I can- 
not too highly recommend this procedure, which always requires close at- 
tention. I have employed with it on the outside, an ointment of boracic 
acid, the formula for which will be found on a subsequent page. J. C. 



APPLICATION OF THE DRESSING. 43 

provoke suppuration, as customarily happens in ordinary 
dressings. 

In conformity to the principles which we have established, 
the line of union and the free angles of the wound ought 
not to be reached by irritating substances, under penalty 
of the formation of granulations and of suppuration. One 
may, and doubtless should, wash them at the dressing with 
even strong solutions ; but it is undesirable to have irri- 
tants remain in contact .with the denuded parts. Now, the 
dressing constantly disengages carbolic acid, and, to prevent 
its action upon the denuded parts, we employ the protective. 
It has been quite difficult to accomplish the manufacture of 
this, which is made of very thin taffeta silk, gummed, covered 
with copal varnish and dextrine, and thus rendered absolute- 
ly impervious to carbolic acid. This material, which is green 
and very pliable, is placed accurately over the wound ; we 
cut a narrow strip of it, which overlaps the wound a very 
little, and over this apply the antiseptic gauze. 

We come now to the application of the dressing, and the 
arrangement of its constituent parts. 

The Dressing. 

The piece of protective is wet in the weak carbolized water 
to divest it of all germs, for in itself it has no antiseptic qual- 
ity. It is placed upon the wound, which it should overlap 
but slightly, in order that the discharge may come as soon as 
possible to the gauze, the antiseptic substance. 

Then we take some pieces of the antiseptic gauze, and, 
having soaked them in the weak solution, wring them out 
and place them directly upon the protective. This precau- 
tion is necessary in order that the gauze may surely be anti- 
septic, because it gives up the carbolic acid but slowly, 



44 ANTISEPTIC SURGERY. 

and, during its exposure to the air, germs may be deposited 
which it is essential to destroy immediately with carbolized 
water. 

For the same reason, we wet slightly with the same weak 
solution the surface of the dressing which is applied to the 
skin. 

The last and principal piece of the dressing is ordinarily 
composed of eight folds of gauze, one upon another. If cir- 
cumstances require, it is made thicker. 

Between the seventh and eighth folds is placed the imper- 
vious cloth or mackintosh, with the smooth surface turned 
towards the wound. The dressing ought to extend a con- 
siderable distance beyond the wound, and, if it is applied to 
a limb, it should reach entirely around it. 

The dressing ought to be crossed as much as possible, in 
such a way that the fluids in draining can find no gap and 
will be obliged to run over the greatest possible extent of 
the dressing. 

The mackintosh should be placed between the last layers 
of the dressing, because otherwise it does not lie close enough, 
and may allow spaces to form under which air may pass, 
and thus there be developed phenomena of infection, which 
can be avoided by this precaution. 

The dressing should be kept in place by bandages made of 
antiseptic gauze. This kind of bandage is extremely con- 
venient, does not slip, and is very firm and strong. Its 
strength is such that in certain resections, particularly those 
of the elbow, we can dispense with splints, if we apply these 
bandages properly; they are fastened with^pins, or by tying 
two free ends. 

By the assistance of these gauze bandages, the dressing 
ought to be so well fixed in place that it will not slip. To 
this end the bandage is moderately tightened. 



MODIFICATIONS. 45 

The better to hold it firmly upon the limbs, Lister usually 
places outside the dressing at its extremities two rubber straps, 
which by their elasticity keep the dressing so tight that no 
leakage or current of air can carry germs under the cuirass 
thus formed. 1 

These are the principal points in the practice of the dress- 
ing. But this is subject to a number of conditions accord- 
ing to the circumstances of the case. If the dressing cannot 
be made broad enough, it should be thicker. We use the 
gauze to fill up the hollows by which air may rush in, — the 
axilla, in amputations of the breast; the ear, in injuries of 
the parotid region, etc. ; and the simple or antiseptic wadding 
around the edge, in all cases where it is needed to complete 
the closure of a dressing which has a tendency to curl up at 
the border. 

For certain dressings Lister still employs a lint saturated 
with boracic acid, well prepared in Edinburgh, and very con- 
venient, particularly when the correct application of the 
dressing just described is impossible. 

But for all these details, the experience and ingenuity of 
the surgeon must come into play ; and when he knows the 
principles, he should seek for everything which will assist him 
in their application. 

Among the accessory means I will give a description of the 
compression with sponge which Lister recommends. 

When, in the course of an operation, he has made a very 
large wound, after closing it, he thinks it well to exercise 
some compression upon the sac thus formed ; and for 

1 The application of the rubber straps here mentioned is limited 
practically to dressings on the limbs. When the wound is on the trunk, 
a long, elastic bandage may be used to confine the upper and lower bor- 
ders of the dressing in the most desirable position, and yet not be so 
tight as to interfere with the necessary movements of the thorax and 
abdomen. The ordinary suspender- webbing answers admirably for this 
purpose. 



46 ANTISEPTIC SURGERY. 

the first dressing, he applies over a piece of protective a 
sponge of convenient form, soaked in strong carbolized water 
and well wrung out ; over this he puts the gauze dressing 
and the bandages according to custom. The sponge makes 
effectual compression, and besides absorbs and neutralizes the 
fluids which are discharged in abundance. In the subsequent 
dressings, this practice is usually unnecessary. We should 
always be careful to place a layer of protective between the 
sponge and the skin, for without this a kind of blister would 
be formed, and the patient would suffer intensely from burn- 
ing. This is one way of practising compression upon wound 
cavities. 

All the ligatures have been enclosed in the wound, as I 
shall explain presently, and the dressing is adjusted. What 
remains to be done for the patient ? 

We should advise such a position of the wounded part as 
will favor easiest drainage. Generally the dressing is re- 
newed at the end of twenty-four hours, less frequently at the 
end of forty-eight. 

Although the extent of the wound may be small, there will 
be a considerable discharge of serum. This immediate dis- 
charge, abundant after all large operations, is perhaps greater 
after those which are performed by this method, probably by 
virtue of a special action of carbolic acid upon the tissues. 

In uncovering the wound one should take the same pre- 
cautions as before with respect to the atmosphere, the hands, 
and the instruments. Then he will notice if the parts are 
stretched, and if they are not, the tubes are left in place for 
this first dressing ; but, if they are stretched, it is necessary 
to withdraw the tubes to empty them of clots ; and if fluids 
have accumulated, they are forced out by gentle pressure. 

The wound or stump is washed lightly with the strong 
solution, unless it is irritated, even to a slight extent, in 



INDICATIONS FOR RENEWAL. 47 

which case the weak solution should be used. The tubes 
are then cautiously replaced. The sutures are carefully ex- 
amined, that they may be loosened if it is necessary. Then, 
as at the original dressing, we apply — 

First, the protective, after having dipped it in the weak 
solution ; 

Second, some pieces of gauze moistened in weak solu- 
tion ; 

Third, the dressing, — eight layers of gauze, with the im- 
permeable cloth betweerf the last two layers ; 

Fourth, the gauze bandage. 

This dressing ought to extend a good deal beyond the 
region of operation. 

It is not an infrequent dressing ; it is applied often at first, 
less frequently afterwards. The especial guide for its re- 
moval is the amount of discharge. The existence of pain 
would also indicate its removal. 1 

Whenever the discharge appears at the edge of the dress- 
ing and stains it, prudence requires us to remove it in order 
to avoid all chance of the propagation of putrefaction. 

If any odor is detected, the dressing should be absolutely 
distrusted, for it should have no odor at all. 

The perusal of this work will show that there are many 
modifications to be introduced according to the case ; how- 
ever, to give a very striking example of what may be done, 
I may be allowed to quote the report of one of my oldest 

1 After almost any operation there is likely to be some pain, even if 
the wound has been subjected to the anaesthetic influence of the carbolic 
spray ; but there is no occasion to renew the dressing on this account, 
unless the suffering is considerable and persistent. 

Another circumstance which imperatively demands the removal of the 
dressing and the careful inspection of the wound is that harbinger and 
attendant of septicaemia, — the rapid rise of the temperature, and its con- 
tinuance at a point much above 37.7° C. 



48 ANTISEPTIC SURGERY. 

cases, published in the Journal of Practical Medicine and 
Surgery, for February, 1876. This will necessitate some 
repetition, but it seems to me typical enough to aid those who 
wish to apply the method. I give it as an ordinary case, in 
which I think it would have been possible even to abridge 
the treatment some days. 

A man, aged forty-two, entered the hospital during my 
service for treatment of a vicious cicatrix of the left leg. He 
had been burned two years before by melted zinc, and the 
skin of the whole leg was so completely destroyed that one 
could see nothing but a vast, persistent ulcer, suppurating 
and bleeding. This had also produced a permanent flexion 
of the leg upon the thigh, which had not yielded to several 
attempts at extension and division of the ham-string tendons 
in other hospitals. Sinuses, discharging pus profusely, kept 
breaking out on the internal aspect of the thigh, and he 
urgently entreated to be relieved of this useless and danger- 
ous member. 

It was easy to see at the first examination that the limb 
could never be entirely restored. Still I did not want to 
accede to his desire for an amputation of the thigh ; it seemed 
to me that the sinus might be healed, then the leg removed 
at the upper third, and that he might walk well upon the 
flexed knee. 

I first treated the sinus of the thigh ; the inflammatory 
phenomena abated as the abscess disappeared, and I resolved 
to proceed to amputate at once. 

On the tenth of November, 1875, I amputated the leg at 
the upper part by the circular method. 

I had great difficulty in finding enough skin to make even 
a scant covering. By sawing the bone at the highest possible 
point, I was just able to close the wound. 

I applied five catgut ligatures to the vessels, and then 



AN INSTRUCTIVE CASE. 49 

sewed up the entire wound, excepting the two extremities. 
I took also a deep suture with lead plates at each end of the 
wire, to assist apposition. 

At each side of the stump was inserted a straight drainage- 
tube, fastened with a thread to keep it in place. The dress- 
ing was placed over all. 

The operation was performed with all the precautions 
suggested by Professor Lister, which are thus summed up : 

I washed the operating field with a strong carbolic solution 
(one part of glacial acid to twenty of water). 

The instruments and sponges were placed in the same 
solution. 

The hands of the operator and assistants were washed in 
the weak solution (one part to forty of water). 

A spray of the same solution was thrown upon the field of 
operation from first to last. 

Catgut ligatures were used and cut short in the wound. 

An occurrence worthy of consideration marked the end of 
the operation. I did not employ the system of Esmarch to 
prevent bleeding, but, as I am accustomed to do, made com- 
pression at the upper part of the limb with an india-rubber 
band. In similar cases it often happens that there is indefi- 
nitely prolonged oozing of blood from the entire surface of 
the wound. Following in this the practice of Professor 
Lister, I proceeded with moderate speed, and inserted the 
sutures. 

Over all was placed the dressing : first the protective, 
then the antiseptic gauze, last the mackintosh or impervious 
material. 

I renewed the dressing the next day. There was no 
change ; still there had been considerable discharge into the 
dressing, which was odorless. The stump being distended 
by the effused blood, I loosened the deep suture ; I removed 



50 ANTISEPTIC SURGERY. 

the drainage-tubes to cleanse them, taking good care to evac- 
uate the effused blood, and, the stump having been washed 
with the strong solution, the dressing was replaced for forty- 
eight hours. 

On the thirteenth of November, I removed the dressing. 
This time there was little discharge ; there was a small 
amount of brown liquid in the tubes, which I withdrew to 
wash and shorten. The stump, which was smaller and not 
changed in color, was bathed in the strong solution, and the 
dressing was renewed. 

On the sixteenth of November, I again renewed the dress- 
ing ; I took out the stitches, the union was perfect ; I removed 
the tubes and shortened them considerably. I found in the 
dressing and in the tubes a few drops of a puriform liquid, 
which was without odor. I repeated the bath with the strong 
solution. 

As all the conditions had been perfectly complied with, I 
was annoyed by the presence of these drops, which, though 
not pus, were at least puriform, and I reflected on their 
possible origin. I thought that it might be attributed to 
excessive irritation of both extremities of the wound, and I 
resolved not to use the strong carbolic solution in renewing 
the dressing. 

At the fourth dressing, on the twentieth of November, 
the appearances were the same ; the liquid in the tubes was 
similar. I shortened the tubes very much, and contented 
myself with washing with carbolic water of one part to 
forty. 

At the fifth dressing, on the twenty-fourth of November, I 
only found some drops of cloudy fluid, the dressing being 
hardly stained. 

At the sixth dressing, on the twenty-ninth of November, I 
withdrew the drainage-tubes, which had been shortened to 



RAPID RECOVERY. 51 

their minimum the preceding time, and washed with the weak 
solution. 

Five days after, the fourth of December, when I took off 
the dressing, it was not moist, everything was healed, and I 
redressed the wound only because I had the materials pre- 
pared. 

On no day did the patient have real fever. The tempera- 
ture on the first nine days was as follows : first day, evening 
38.2° C; second day, morning 38°, evening 38.3°; third, 
morning 37.4°, evening 3f.8° ; fourth, morning 37°, evening 
38.4° ; fifth, morning 37.2°, evening 38.4° ; sixth, morning 
37.2°, evening 37.6 ; seventh, morning 37.2°, evening 37.4° ; 
eighth, morning 36.8°, evening 37° ; ninth, morning 36.6°. 
After this the morning temperature generally ranged from 
36.4° to 36.8°, and that of the evening never exceeded 
37.4°. 

Here was a man entirely cured in twenty-four days ; and 
still there was nothing extraordinary in the case, for the 
phases of repair were exactly those indicated by Professor 
Lister. The wound, maintained in apposition, gradually 
closed at the two extremities ; there was an ordinary amount 
of discharge. The catgut ligatures remained in the stump 
without creating any irritation. 

The blood which was effused into the stump behind the 
sutures, and the presence of which I can prove by my 
internes, and by the students who followed my service, did 
not putrefy and did not interfere with the process of repair, 
as it always does in other methods of dressing, as all the 
advocates of union by first intention acknowledge. 

There was a curious incident, which seems to decidedly 
support the Lister theory. Having seen that a puriform 
liquid was formed, I supposed that it was caused by excessive 
irritation of the wound from a strong solution ; I employed a 



52 ANTISEPTIC SURGERY. 

weak solution, and, after the next dressing, there was no 
more discharge. 

There was no suffering. His temperature being but slightly 
elevated, the patient had only a mild traumatic fever, and 
this conforms well to the theory. 

So much for the physiological process. Now look at the 
result as it concerned the patient. In twenty-four days a 
man in a deplorable state of health recovered entirely from an 
amputation of the leg at the upper third. The sinus of the 
thigh, which was discharging pus, cicatrized spontaneously. 
There was no suffering. There were only six dressings. 

Eight days afterwards this man was walking about on a 
wooden leg, and has had no suffering since ; I heard from him 
two years after. 



CHAPTER IV. 

The Dressing of Old Wounds which have or have not 
Fistules. — Wounds in the Neighborhood of Natural Open- 
ings. 

Surgery is not simply operative, nor is it practised solely 
for people who present themselves with unbroken skin. Is it 
possible, when a wound has been exposed to the air, or when 
it has suppurated, to purify it sufficiently to make antiseptic 
treatment successful ? 

Yes, certainly ; and this answer applies to both classes of 
cases, — recent wounds, in which granulations have not yet 
formed, and wounds which have been suppurating for a 
longer or shorter time. 

A recent wound, without granulations. — If it is fresh and 
still bleeding, it will suffice to give it a bath in the strong 
solution. If it is very tortuous, or if it has been exposed to 
the air for a long time, we employ a still stronger solution, 
ten parts of carbolic acid to one hundred of water. 

We may even use an alcoholic solution, containing twenty 
parts of carbolic acid to one hundred of alcohol. We can 
purify it sufficiently, as large wounds in bones, complicated 
fractures, which have received the advantages of antiseptic 
surgery, abundantly testify. 

In case this strong alcoholic solution is employed in very 
tortuous wounds, as it is a powerful caustic, it is well to re- 
sort to a special operative procedure. Instead of injecting it 
freely and at random, it is a good plan to guide it into the 
wound by the aid of a sound or a caoutchouc tube fitted to 



54 ANTISEPTIC SURGERY. 

the end of a syringe. By injecting thus, the quantity of the 
liquid is graduated at pleasure, and there is no forcing, no 
tearing of the areolar tissue, no spreading on to or burning of 
all the surrounding parts. 

Wounds which have been suppurating for a longer or shorter 
time. — When, however, established suppurations, old wounds, 
and particularly fistules which remain in the operating field 
are in question, antiseptic surgery is untrustworthy. It pro- 
bably happens in such cases that the granulations retain 
accumulations of germs which cannot be affected by the 
fermenticide action of even a very strong carbolic injection ; 
and, little by little, the wound, which at first was exempt 
from suppuration, is invaded by it, as with an ordinary 
dressing. 

Lister had experienced frequent failures, when he saw 
Volkmann, of Halle, employ a method which has since given 
him the best results. 

It consists, in brief, in restoring the wound to its primitive 
conditions of vitality. It is a veritable freshening practised 
upon the entire surface, even into its most remote recesses. 

To bring back to its normal state a wound which has sup- 
purated, we must carefully destroy all the granulations, all 
the fungous excrescences, which are found upon its surface ; 
then it is particularly important to penetrate into the fistulous 
passages and extirpate the granulations in them. 

This is very difficult to accomplish, but it can be done with 
the sharp spoon, which Volkmann has invented. This is a 
little cup of steel, very narrow and made in various shapes, 
mounted upon a long stem, and having a sharp edge. This 
is carried into the fistulous tracts, which are then scraped, 
and the detached granulations are brought out. Thus the 
passages are swept, as it were, in their entire extent. This 
manoeuvre must be insisted on, as a means of destroying the 



CHLORIDE OF ZINC. 55 

greatest possible quantity of granulations. Upon the wound 
and in the fistules thus made bare, it is necessary to exert an 
antiseptic action. For this purpose recourse is had to a 
powerful disinfectant and caustic, reserved for these cases, 
the chloride of zinc, of which we inject an eight per cent, 
aqueous solution. 

This injection is gently thrown into the fistulous passages, 
without rupturing their walls, so as not to introduce into the 
areolar tissue a liquid which will produce gangrene. 

Its action would be uncalled for in a widely open wound 
which had suppurated at one point only, if we could excise 
and detach all that had suppurated. 

By the aid of bent scissors I have succeeded in denuding 
the internal surface of quite a large portion of a small flap of 
an amputation of the thigh, the upper sinus of a white swell- 
ing of the knee. All the parts having been excised, the flap 
was carefully washed with the strong carbolic solution, and 
the wound was closed without delay. 

But when we come to fistules, to burrowing sinuses which 
have suppurated for a long time, the action of chloride of 
zinc is indispensable, and it is almost always efficacious. 

I have often practised this method, and have seen the 
most remarkable results from it. I have been able, for ex- 
ample, to render completely aseptic an immense purulent sac, 
which filled the whole buttock of a girl, producing an inter- 
minable suppuration. I laid open a part of the fistula. The 
washing out brought away a handful of fungosities and some 
debris of bone. I then injected chloride of zinc, united the 
parts with three points of suture, and put in a drain. Heal- 
ing was accomplished in a few days, and an examination of 
the patient months afterward revealed no return of the 
disease. 

One can hardly imagine how favorable to the healing pro- 



56 ANTISEPTIC SURGERY. 

cess is the condition in which surfaces are put by this kind 
of preparation. Perhaps it is best seen in resections of the 
joints. 

When the wound is thus cleansed it is in the condition of 
a fresh one. As such it should be treated, and will unite 
according to all the rules. No different directions are re- 
quired from those which are needed in the case of a recent 
wound. 

The antiseptic power of chloride of zinc is such that it 
should be employed in these cases and in all in which doubts 
of the efficacy of carbolic acid are entertained. Socin, of 
Bale, it is said, goes further, and washes recent wounds with 
the zinc solution. We know that as soon as they are covered 
with a delicate, white eschar, rapid union will easily take 
place. I have often employed this procedure, and like it for 
some large operations ; but I prefer to avoid it whenever it is 
possible, because the irritation from it is greater and the pain 
which follows the operations is very severe. 

Wounds in the vicinity of natural orifices. 

The action of chloride of zinc, which renders organic sub- 
stances imputrescible, is such that it permits us to make a 
dressing which is incompletely antiseptic, but still very valu- 
able whenever the aseptic dressing is not applicable in its 
entirety. This is the case, for instance, in operations about 
the natural openings, — the anus, the mouth, etc. 

These operations are made without the spray, after prelim- 
inary washings. After the operation and before the dressing, 
the lips of the wound are carefully impregnated with an 
eight per cent, aqueous solution of chloride of zinc, and then 
united. A drain is inserted, if possible, and then the wound 
is protected by folds of carbolized gauze, or better by linen 
saturated with boracic acid ointment and by borated lint. 



CHLORIDE OF ZINC. 57 

The baths are of carbolic acid or chloride of zinc ; but we 
must remember that the antiseptic action of the latter lasts 
at least two or three days, and the better way is to leave the 
dressing in place for that time without disturbing it. Then 
a carbolic acid wash is used, and the dressing is renewed. If 
any portions of the wound are not healed, we touch them 
anew with the chloride. This method may be infinitely varied 
and accommodated to the requirements of each wound. 

I cannot, however, end this chapter on the treatment of 
parts which have suppurated without remarking that Lister, 
when he finds diseases which have given rise to suppuration 
of a bad nature, even before the contact of air, employs the 
chloride of zinc. I have seen him, for example, in the case 
of a young boy, attacked with osteomyelitis of the tibia, lay 
open the periosteum, and separate it carefully, especially 
where he could see drops of pus. Then, upon all the gaping 
parts, opened from the knee to the lower third of the leg, he 
freely poured a solution of chloride of zinc ; and this opera- 
tion was repeated the next day at those points where swell- 
ing still existed. 

The reaction was less active than one would have expected, 
and this child, who presented typhoid symptoms of the most 
menacing character, completely recovered, and preserved his 
limb intact. 

I myself have used the chloride successfully, as I shall ex- 
plain when treating of abscesses. 

5 



CHAPTER V. 
Boracic Acid and Unirritating Dressings. 

In certain cases, where, on account of extreme sensitiveness 
of the skin, carbolic acid produces a kind of eczema, and in 
others, where there is little to be discharged by drainage, 
antisepsis may be obtained very excellently by the aid of 
boracic acid. It should be remembered, however, that this 
is a far less powerful agent than carbolic acid, and that, in 
consequence, much greater care is necessary in using it. 

Wounds are prepared exactly as in cases where carbolized 
gauze is employed, by a bath of carbolic acid. Then layers 
of boracic acid lint are applied directly over the sutured sur- 
face, the undermost being wet in a saturated, aqueous solu- 
tion of the acid, — four parts to one hundred. The protective 
can be dispensed with, as the boracic acid is hardly at all 
irritating ; but in some cases I employ it just the same. 

A sufficient thickness of lint having been applied, the im- 
permeable layer is added, and then the dressing is firmly 
secured. If there is a considerable amount of discharge, the 
dressing must be renewed very often ; but ordinarily we 
employ this kind only when there is a moderate drain, and 
then it has to be renewed but rarely. 

Instead of a dry dressing, it is frequently preferable to 
make use of one in which boracic acid ointment is an element. 
For this purpose, a strip of lint is smeared with a layer of this 
salve, and is applied directly to the wound, and over this are 
placed the folds of boracic lint, as has been already described. 



BORACIC ACID. 59 

This unguent of boracic acid is very mild and unirritating, 
and, in erythema, it is of conspicuous service. In fact, I 
have often applied it all around the wound, while using the 
antiseptic dressing of carbolic acid, and find that, in addition 
to the antiseptic role which it plays, it has a kind of protec- 
tive action upon the wound. This is an especially good dress- 
ing in all plastic operations. It is particularly useful at the 
last part of the treatment of large wounds, when discharge 
has nearly ceased, and only superficial parts remain to be 
healed. 

The dressing of wounds which cannot be closed. 

If it is not practicable to bring the lips of a wound in 
apposition, the antiseptic method may be used with profit, 
without, however, getting the benefit of one of its most 
important advantages. 

In such a case, it is best to close the wound as far as possi- 
ble, and shield with protective the portion which cannot be 
united. At each dressing, scrupulous care should be taken 
not to cause irritation by the use of a strong solution in 
washing. 

If the direct, irritant action of the carbolic acid in the 
dressing is feared, that part of the wound may be dressed 
with the ointment of boracic acid and plentifully covered 
with the lint. 



CHAPTER VI. 

The Time when the Antiseptic Dressing may be omitted. 

There is one condition of success of so great importance 
that it is desirable to devote a special chapter to it. It has 
been advised to omit antiseptic precautions as soon as the 
dangers which have menaced the life of the patient have 
disappeared, and not to continue them to the very end of 
treatment, because the use of carbolic acid has been thought 
to retard the last steps of the reparative process. This, how- 
ever, is a deplorable mode of procedure. 

Until cicatrization is perfect, until the repair of the wound 
has been absolutely finished, we should persevere in the anti- 
septic protection. 

If we desert a wound too soon, the surface, even though it 
be very small, suppurates, and this prolongs by just so much 
the work of healing. If there happens to be an opening into 
the interior, a part of the tract of the tube unclosed, suppura- 
tion is certain to occur ; if there is an extremity of bone at 
the bottom, we have osteitis, partial necrosis, and persistent 
fistulas, just as if an ordinary dressing had been used. In a 
foreign hospital, where two surgeons applied the Lister dress- 
ing correctly enough, I have seen a series of amputations. 
In one service, the patients had pain, redness, swelling of the 
bone, and fistulas : in this service, as a rule, the dressing 
was omitted after a little time. In the service of the other 
surgeon, the appearance of the stumps was perfect, there was 
nothing whatever to criticise : in these cases, the dressing 
was continued until cicatrization was complete. 



WHEN TO OMIT THE DRESSING. 61 

It is not always necessary to maintain precisely the same 
dressing. In the first part of the treatment, the discharge 
becoming less and less abundant, according to the progress 
of repair, the dressing is changed more and more rarely. 
Later any convenient dressing may be used, provided the 
principles of antisepsis continue to be followed. 

Thus, boracic acid lint is very useful in the latter stages of 
the cure. It can be put directly on the wound, or separated 
from it by protective. Before it is applied, it is well to wet 
it in a concentrated solution of boracic acid. If there is very 
little discharge, we can dispense with the impermeable layer 
about it ; but, for my part, I prefer to continue its use. It 
gives more security, and prevents the too rapid drying of the 
secreted fluids. 

At this period, the carbolized wadding, or better still the 
salicylic wadding, or the prepared jute, can be used with ad- 
vantage. In a word, as the protection of the wound is much 
easier at this time, we have far more liberty in the selection 
of means. When healing seems to be accomplished, if there 
is any doubt about some corner of the scar which is covered 
with a scab, it is wise to apply a final dressing, which should 
be left in place without renewal. 

In the course of treatment, the management of the tubes 
is sometimes difficult. As a general rule, after the first days 
they should be much diminished in size. In fact, from this 
time the discharge becomes inconsiderable ; but before finally 
withdrawing the tube, we must make sure that there is no 
chance for the accumulation of fluids in the deep parts. 

Many surgeons at the beginning of their antiseptic practice 
leave the tubes in the wound too long, and thus cicatrization 
is retarded. 



CHAPTER VII. 

The Suture and Closure of Wounds. — Superficial and Deep 
Sutures. — Compression with Carbolized Sponge. 

There has been a great deal of talk of late about the suture, 
and it has even been asserted that the especial kind of suture 
is the most original thing in the Lister dressing. One must 
be very ignorant of the method to make such a statement. 
Neither the single nor the double suture is an integral or 
necessary part of an operation. There are indications for it, 
it may be employed, and may be very useful with particular 
precautions. 

The more exactly and carefully the suture is made, the 
more rapidly will the wound heal. Nevertheless, it may 
be truly said that, with the antiseptic method, union is so 
easy that excellent results are obtained, even when coapta- 
tion is not perfect. 

Ordinarily a superficial suture is made with metallic thread, 
and Lister usually employs also the deep suture, but this is 
not his invariable practice. I have seen him make a number 
of operations without resorting to it in any way. Every 
surgeon of much experience will easily understand the reason 
of this. The best of even superficial sutures compresses and 
strangles the tissues ; and, if it is not watched, little points 
of suppuration are formed. Lister habitually cuts the sutures 
early in order to avoid this complication. 

He uses coarse metallic thread, particularly in making the 
deep suture ; but various other materials may be employed, 
such as carbolized silk, catgut, horsehair, and crin de Flor- 



FREE USE OF SUTURES. 63 

ence. Although some imitators of Lister advise the hare-lip 
suture, I consider it defective and useless, and in my anti- 
septic operations have given it up entirely. 

A very striking fact to the surgical mind is the freedom 
with which the suture may be used. The time has gone by 
for discussion of the question of closing stumps after amputa- 
tion. The suture is made boldly in wounds of every kind — 
in amputations, wounds of serous membranes, of articulations, 
of the scalp. I have used it after removal of a sebaceous 
cyst of the head ; I have employed it upon the scalp after 
ablation of a lipoma ; but I have made it oftener after open- 
ing immense abscesses, and have obtained perfect reunion of a 
portion of the opening after reducing the aperture of exit to 
its necessary dimensions. 

Apposition is accomplished very easily, and we pay no 
attention to certain precautions which were recommended 
in former times. The presence of ligatures in the wound 
gives no concern ; we care very little about removing every 
drop of blood, for what we desire is the asepticity of the 
wound — its surgical cleanliness, — and this is not interfered 
with by the presence of little clots. If the parts have been 
carefully washed with the chloride of zinc solution or the 
strong solution of carbolic acid, we shall obtain excellent re- 
union of surfaces which seem to present real, though minute, 
sloughs. We get it, also, when, the circumstances not ne- 
cessitating so powerful an antiseptic action, we use weak 
carbolic solutions, or even the solution of boracic acid. 

The superficial interrupted suture is the most convenient 
and the easiest to make. I usually take the stitches more or 
less deeply, according to the depth of the wound. 

When there is difficulty in bringing the superficial parts in 
apposition, repair is greatly facilitated by inserting some deep 
sutures. Lister advises their use as follows : — 



64 ANTISEPTIC SURGERY. 

He takes a needle threaded with coarse silver wire, and, 
introducing it at some distance from the wound, he thrusts it 
to the very bottom of the solution of continuity, then carries 
it from within outward on the other side, and brings it out at 
a point opposite that of entrance, and equally distant from 
the incision. Then he twists each end of this wire around a 
leaden plate, which serves to keep it firmly in place. The 
application of the first plate is much easier than that of the 
second. In order to secure this, it is necessary to forcibly 
support the lips of the wound, which tend to gape. We are 
thus sometimes enabled to bring together parts so far sep- 
arated that at the first glance apposition seemed impossible. 

The suture being made, it must be protected. Drainage 
should be carefully provided, not only because accumulation 
behind the suture tends to break it mechanically, but also 
because excess of tension causes inflammation and suppura- 
tion, which would destroy the young products by which re- 
pair is effected. This result is easily obtained by the superior 
method of drainage pursued by Lister. 

The suture, however, needs this adjuvant only at the first. 
The presence of a deep stitch demands particularly careful 
drainage, without which it forms a decided barrier to the dis- 
charge ; and this is one of the principal reasons for employ- 
ing it only when it is clearly indicated. 

The suture needs to be protected from the irritant action 
of topics, and many fail in their use of it by disregarding the 
theory of the protective, which they neglect to apply. Others, 
always with some special intent, cleanse the wounds, and rub 
the surfaces with antiseptic liquids ; and their superfluous 
neatness only serves to prevent healing. Still others, en- 
tertaining the same views, inject by the tubes liquid anti- 
septics, which they think will favor healing and prevent 
accidents, and they get the diametrically opposite result — 



THE DEEP SUTURE. 65 

remarkable slowness in the reparative process, and failure of 
union at one or more points. 

The deep suture is necessary only when apposition is im- 
possible or difficult, and should be continued the shortest 
possible time, as it is very likely to induce deep suppura- 
tion. I have seen extensive phlegmons result from deep 
sutures which were nearly useless, and which were allowed 
to remain unnecessarily. Even the superficial suture ought 
not to be left too long, and Lister, as I have said, takes 
the greatest care to cut at an early day all or part of the 
stitches. He cuts them without removing them immedi- 
ately, for they can still give some support without irritating 
or compressing the edges of the wound, and can thus be of 
use. 

If, at the level of the deep stitch, there is a little accumu- 
lation of fluid, let out the drop of pus with the point of a 
bistouri, before it provokes the ungluing of the flaps. 

Compression has been advocated as an indispensable 
adjuvant of the suture, and it is doubtless useful when there 
is a large cavity to be filled. Lister recommends an excel- 
lent procedure, which consists of compression with pieces of 
sponge which have been soaked in strong carbolic water. 

The employment of folds of antiseptic gauze, skilfully 
applied, is also very useful ; but forcible constriction is en- 
tirely superfluous. I have had excellent results in some cases 
where compression had been so imperfect that the space 
under the flaps had filled with blood, and in others where the 
violent pain of inflamed parts, such as articulations, rendered 
all compression impossible. 

What shall be the material of the suture ? Whatever it is, 
it is necessary to purify it and soak it in a strong carbolic 
solution. For most cases I prefer silver wire. 

Lister often uses horsehair. 



66 ANTISEPTIC SURGERY. 

Carbolized silk is very manageable, and certain English 
surgeons employ it exclusively. 

Catgut is a good material for suture, but it is not free from 
objections. It swells too quickly, and thus occludes the orifice 
made by its passage, and prevents the escape of liquid along 
the thread. 

Le crin de Florence, the secreting organ of the silkworm, 
seems to be an excellent material for suture. 

Lister is in the habit of putting the stitches quite near to- 
gether. It is best to use a needle of a size a little larger than 
the thread requires, as by this means there is less irritation in 
its track. 

For the introduction of the catgut suture, it is convenient 
to have a special needle, like that of Charri&re, or of Bruns, 
or, what is in my opinion the best of all, a modification of the 
latter suggested by Reverdin, of Geneva. Each of these 
needles has a somewhat spear-shaped point, with a notch on 
one edge, which is closed by a sliding rod. The needle is 
thrust through the lips of the wound, the notch is opened 
by the withdrawal of the rod, the loop of catgut is inserted, 
the notch closed, and the needle drawn back. 



CHAPTER VIII. 

Drainage. 

As I have already said, drainage is of paramount importance. 
The materials used are various, but as yet I have found 
nothing better than the tube of Chassaignac. However, I 
consider tubes of silver, aluminium, or glass very valuable in 
certain cases, and superior to those of caoutchouc ; but as 
satisfactory specimens are not in the market, I will devote no 
space to a description of them. 

Three principal modes of drainage are generally employed : 
with the perforated caoutchouc tube of Chassaignac; 1 with 
catgut, as taught by Dr. Chiene, of Edinburgh ; and with 
horsehair, as proposed by White. 

Whatever may be the material employed, it is indispensable 
to understand certain conditions of drainage. Wounds 
which have been touched by the powerful antiseptics, carbolic 
acid or chloride of zinc, discharge a considerable quantity of 
serosity, which thoroughly saturates the dressings of the first 
twenty-four hours. It is particularly for this discharge at 
the outset that drainage is required, and, this being pro- 
vided for, the quantity of the fluid which is poured out 
diminishes rapidly, and soon drainage is unnecessary. If the 
surfaces of the wound are irritated anew, a fresh discharge is 
provoked. 

1 Excellent and very inexpensive drainage-tubes may be made easily 
of ordinary rubber tubing, which can be cut into pieces of any required 
length. The holes should be of large size, and may be made very nicely 
with ordinary scissors. 



68 ANTISEPTIC SUEGERY. 

As these liquids are serous, slightly thick, tinged with 
blood, or only turbid with altered leucocytes, their discharge 
is easy, and one is surprised at first to see that a drain of 
relatively small size is sufficient to empty a large cavity. 
This is illustrated in the case of a drain placed upright in a 
large articulation, even when the liquids must run against 
gravitation. 

But, although drainage does not require much apparatus, 
at least what it has ought to be efficient and operate in 
the following manner : — 

Lister does not place a drain in a wound from one end to 
the other, as Chassaignac has taught, but inserts one or more 
perpendicularly from the surface to the bottom, thus making 
channels between the apposed surfaces. But these canals 
are incomplete, they are cuts- de-sac ; and, as healing takes 
place from the bottom towards the surface, the tubes are 
driven out. 

Ever}^ day the drain is withdrawn to be cleansed, and is 
shortened to prevent the inner extremity's irritating the parts 
which are healing. 

In inserting the tube with the Lister fistula-forceps, no 
force should be used, lest it excite irritation, and, for the same 
reason, it should not project beyond the surface and lift up 
the dressing. A thread is fastened to the free end for the 
purpose of drawing it out. 

As it is important to avoid all irritant action in the deep 
parts of the wound, Lister carefully abstains at the time 
of the dressings from injecting antiseptics through the drain. 
These retard healing by partially preventing the union of the 
flaps, and exciting suppuration. 

He even goes further. Ordinarily, on the day after an 
operation he considers it advantageous to withdraw the drain, 
as he does in all following dressings, in order to cleanse 



MANAGEMENT OF THE TUBES. b9 

it. But when there has been an outpouring of blood, and 
the tube is embedded in the clot, he advises not to extract it 
at the first dressing. This permits the clot to organize and 
to assist in the repair. If, by the withdrawal of the tube, 
the clot is broken or irritated, it is discharged in pieces with 
the fluids of the wound. After the clot is organized, it acts 
as a sheath into which the tube can be returned when it has 
been cleansed. 

Great attention should be paid to the selection and inser- 
tion of the tubes. They Should be large and strong, and so 
placed that their lumen may not be effaced ; they should 
have no elbows, and should not be pressed by any point of 
suture. In order to fulfil these conditions, it is well, at the 
time of the operation, not to insert them until the suture is 
nearly complete. 

In the subsequent dressings, not only is the tube to be 
shortened, but it is to be superseded by tubes progressively 
diminishing in size. 

I am in the habit of using two tubes of small calibre side 
by side, instead of one of large size. If need be, I employ a 
fagot of little tubes, and this method presents several advan- 
tages : in the first place, the capillary oozing takes place upon 
a more extensive surface, and drainage is accomplished more 
easily ; then, on the next day, one may remove a single tube, 
and, if the discharge is moderate, leave it out, or, at any rate, 
stop using it after the second or third day ; finally, tubes of 
moderate calibre are much more easily introduced, even when 
there is quite a number. We may use different sizes in the 
same bundle. 

For the introduction of tubes the fistula-forceps is very 
valuable. The tube being seized in the direction of its 
axis is easily inserted. Lister sometimes even avails him- 
self of the almost sharp extremity of the forceps to make 



70 ANTISEPTIC SURGERY. 

counter-openings through which he draws the rubber 
tube. 

Drainage with catgut was proposed by Dr. Chiene, of 
Edinburgh, who insisted upon the superiority of a drain 
which would not need to be removed and which, after it 
had performed its work, would be absorbed. It consists of 
from six to twenty pieces of catgut in a bundle, which is 
used instead of the tube of caoutchouc. The extremities 
are allowed to pass slightly beyond the surface of the skin. 
The fluids filter by capillarity along the threads, and after 
some days — the time varying according to the number of 
threads employed — the drain is absorbed, and reunion is 
accomplished. 

By this method the deep irritations caused by displace- 
ments of the tube are avoided; and, far from hindering 
repair, the foreign body in a way assists it. Reunion is 
effected much more rapidly, and consequently recovery is 
less protracted. An interesting work by Dr. Jules Boeckel, 
communicated to the Surgical Society, gives support to this 
view. He cites many very remarkable observations made in 
cases of large amputations. 

I think, indeed, that this method may be applicable in some 
cases, but I do not consider it as sure as ordinary drainage. 
Having tried it a few times, I have noticed that it may easily 
occasion unpleasant accidents. The catgut being put in 
place immediately swells, and, if the wound is a little tortu- 
ous, or the orifice of exit of the drain rather narrow, the 
opportunity for the escape of fluids is insufficient, and it 
becomes necessary to withdraw the drain. 

In short, I believe that this kind of drainage possesses real 
advantages as regards rapidity of cure, but it is somewhat de- 
fective as regards security. I am more favorably disposed 
towards drainage with horsehair, advised by Mr. White, of 



HORSEHAIR DRAINS. 71 

the Nottingham General Infirmary, and adopted more recently 
by Mr. Lister. 

This consists of a bundle of well-washed horsehair, satu- 
rated in the strong carbolic solution. The deep extremity 
has a hair tightly wound about it and tied. These drains 
are used just as are the others which have been described. 
The fluids filter by capillarity along the hair, which does not 
change in size or become clogged, and thus gives excellent 
drainage. If it does not work well, it may be removed and 
reinserted, and it may even be diminished in size without 
removal, by withdrawing a number of hairs. I have seen 
Lister use horsehair in almost the same conditions as the 
tube of rubber, over which it has the advantages of drain- 
ing as well when bent as when straight, and of not con- 
tracting the bad odor which the caoutchouc tubes sometimes 
acquire. 

Admitting that this material is not generally employed, 
still it is useful to know of it, for it is found everywhere, 
and may be very serviceable, particularly in the country, 
where the dressings must often be made from whatever is at 
hand. 

While on this subject, I may mention that wounds of small 
extent may be sufficiently drained by any substance which is 
impermeable on account of a smooth surface, such as bits of 
taffeta, gummed cloth, rubber thread or ribbon, etc., and 
in certain cases it is desirable to employ one of these sub- 
stances. I emphasize this, because I have drained with all of 
them ; fine layers of rubber in particular have rendered good 
service in minor operations. In bundles they may sometimes 
take the place of a large drain. 

Recently there have been made absorbable drains, per- 
forated and channelled like the others. I have no personal 
experience with them, but I have doubts about their coming 



72 ANTISEPTIC SURGERY. 

into general use, since drainage by the resisting tube has so 
many advantages. 1 

The surgeon should aim at reducing the time of drainage 
to a minimum. M. Jacques Reverdin recently informed me 
that for some time he has derived advantage from greatly 
shortening the period of drainage. He more frequently re- 
frains from replacing the drain after its removal. 

1 The drainage-tubes referred to were introduced by Neuber, of Kiel, 
and are made of decalcified bone or ivory. They disappear by absorp- 
tion after they have performed their work. Their advantages are those 
claimed for the catgut drains. Esmarch and others have used them ex- 
tensively, and are enthusiastic in their praise. The method of prepara- 
tion is as follows : — 

Into a solution of one part of hydrochloric acid in two parts of water 
put the drains which are to be decalcified, and let them remain for ten 
hours. Then remove them and wash them in a five-per-cent. carbolic 
solution, and preserve in ten-per-cent. carbolic oil. 

As these tubes are quite costly, it has recently been proposed to use 
the shafts of the long bones of chickens for this purpose. 



CHAPTER IX. 

The Antiseptic Spray. 

The production in the atmosphere in which the operation is 
performed of a spray of- carbolized water to protect the 
wound from the torrents of germs which the atmosphere is 
constantly pouring upon it, and which are peculiarly a 
menace in hospitals, constitutes a great advance upon Lister's 
first attempts, in which rapidity of operation and of dressing 
under an oiled compress afforded only partial protection. 

This procedure consists in enveloping the region of oper- 
ation in a cloud of pulverized carbolic acid. It is not in- 
tended, as many suppose, to cover the wound with a fine 
shower of the acid ; and it is even well to remember that 
this rain, if prolonged and too directly applied, will irritate 
the integument of the patient and also the hands of the 
operator. 

The spray is intended to destroy the germs and bacteria 
in the air of the operating region. Does it act by directly 
killing the germs ? Does it act by driving them upon the 
antiseptic soil where germicide washes are flowing? It is 
difficult to state its mode of action, but it is certain that it 
absolutely changes the conditions of operations, and no ex- 
periments made in circumstances different from those in the 
operating room can avail against the actual experience of 
surgeons who have tried antiseptic surgery with and without 
the spray. 

Now, experience is very clear on this point. We have 

6 



74 ANTISEPTIC SURGERY. 

been able to have uniformity in the results of operations 
only since the introduction of the spray ; operations which 
open great cavities, the recesses of which are inaccessible to 
washes, — gastrotomy, herniotomy, the opening of large ab- 
scesses, arthrotomy, — are dangerous and often fatal without 
the spray. 

The importance of the spray is somewhat diminished if 
the air is extremely pure, but it is well not to count too much 
on it in the above-named operations. 

For operations in which the traumatic surface can be 
washed, drenched with a great deal of water, the spray during 
the operation is less important. Thus, surgeons who employ 
washes as largely as Volkmann, who pours the strong car- 
bolic solution upon the wounds from a watering-pot, may 
in certain cases neglect it ; but it is always necessary to have 
recourse to it in the dressings. Lister prefers not to wash 
and handle wounds under a current of strong water, and 
therefore holds tenaciously to the spray. 

The weak carbolized water (one to forty) is sufficient for 
the spray ; but it is to be remembered that this is true only 
when the hand-apparatus is used. With the steam apparatus, 
which dilutes the jet of spray with water from the boiler, 
somewhat stronger solutions should be employed (one to thirty 
or forty). 

It is very important to use only very pure carbolic acid for 
the spray, that neither patient nor surgeon may be incom- 
moded. There is a great deal of difference between the 
carbolic acids ; in England and Germany the spray is not at 
all disagreeable, as the products employed are pure. If the 
purity of the acid permits the omission of alcohol from the 
solution, the spray is much less offensive to breathe. 

An assistant takes one of the numerous spray-producers, 
and stands with it at a distance, which is determined by its 



THE APPARATUS. 75 

power of projection, in such a manner that the wound is 
always at the point where the cloud is the largest and the 
spray the finest. It is the duty of the assistant to look out 
for the continuousness of the stream, to prevent it from de- 
viating, and to keep it from inconveniencing the operator and 
the patient. If there is any interruption of the stream, he 
must cover the operating field with a compress saturated with 
a one-to-forty solution until the jet can be renewed. 

All spray-producers are constructed upon substantially the 
same principles. A powerful stream of air or steam is driven 
through a tube, whose orifice of exit is very small and placed 
just over the mouth of a similar tube, the lower end of which 
is immersed in the liquid which is to be reduced to a spray. 
The rapid current of air or steam produces such a reduction 
of pressure in the second tube that the liquid rises in it ; and 
as soon as it emerges from the upper end, the impact of the 
air or steam breaks it into a spray of such fineness that the 
process is sometimes extravagantly called atomization. In an 
apparatus which is driven by a bellows, the weak carbolic 
solution may be used ; but in one worked by steam power, 
the strong solution is necessary, because the steam dilutes the 
liquid and consequently weakens it. 

The simplest of the spray-producers is that of Richardson, 
the bellows of which is worked by the hand. The weak 
carbolic solution is employed in using it. 

There are some decided objections to this apparatus ; the 
spray wets and chills the patient too much, almost freezes the 
surgeon's hands, and is of too small volume ; the assistant 
who works it soon becomes fatigued ; and, if it gets clogged, 
grave inconvenience results. One of these objections may be 
avoided by using a recently constructed improvement of 
Collin, in which a little movable rod is placed inside the suc- 
tion tube, and so arranged that by pushing it upwards, any 



76 ANTISEPTIC SURGERY. 

obstruction to the flow of liquid through the aperture of exit 
is instantly removed. 

It is very inconvenient to use several of these machines at 
once, and so I have had Collin make me a spray-producer on 
the same principle, with three beaks instead of one. The 
volume of spray from this triple apparatus is sufficient for a 
large operation, especially if the beaks are made to diverge. 
If one of the tubes should chance to become obstructed, the 
spray will still be abundant, and no trouble ensues. The 
bellows is very large and is worked by the foot without 
fatigue. Unfortunately this apparatus wets the parts a good 
deal, and chills them after a time, even when hot liquids are 
used. 

The bellows apparatuses may properly be used in small 
operations and in dressings, and they have the advantage of 
those driven by steam in requiring no expenditure of time in 
preparation and no consumption of alcohol. The fineness of 
the tubes sometimes occasions inconvenience, as the least dirt 
chokes them. The end of the suction tube which is immersed 
in the fluid should be furnished with a little linen filter, and 
a similar device should be employed at the free extremity of 
the bellows, to prevent the particles of all sorts, which are 
always floating in the air, from being drawn into the tube. 

For all major operations the steam apparatus is indispensa- 
ble. It keeps at work a long time without attention, and the 
spray which it furnishes is perfectly continuous and finer than 
that from the air machines. 

Lister's steam spray-producer is, in all respects, an excel- 
lent instrument, and its perfection is an abundant excuse for 
the complexity of its structure. It consists of a boiler with 
a safety-valve, the escape-tube of which is provided with a 
spout through which the stream of steam is projected. The 
lower tube meets this at an acute, instead of a right, angle, — 



STEAM SPRAY-PRODUCERS. 77 

an arrangement upon which Lister lays great stress. The 
boiler is heated by a spirit-lamp, the circular wick of which 
heats a tube at the extremity of which burn the vapors of 
alcohol which are set free. There is an arrangement by 
means of which the flame can be increased or diminished, 
according as more or less steam is needed. In the English 
hospitals the lamp is often surrounded by a wire gauze. A 
vessel for the carbolized water is fastened in front of the 
lamp. This apparatus is inconveniently heavy and very 
costly ; but it gives so very fine a spray that the operator is 
not wetted at all, and it runs, according to the volume of 
spray, two hours or more, that is, all the time necessary for a 
capital operation. 

M. Collin, our ingenious instrument-maker, has made me 
an apparatus which, it seems to me, could be improved only 
by borrowing all the constituent parts of Lister's spray- 
producer. It presents some modifications, some perfection of 
detail, and, best of all, is so much less expensive that the 
most impecunious hospital can afford to buy it. 

It differs materially in form from Lister's. The boiler is 
spherical, that shape being chosen on account of the ease of 
heating and the greater strength. Like all the steam appar- 
atuses it has a boiler, which is heated by an alcohol-lamp. 
At the upper part of the boiler are a sort of funnel which 
gives an opportunity to see when the boiler is full, and thus 
makes the employment of a movable funnel unnecessary; a 
safety-valve ; two tubes for the exit of steam, which can be 
moved up and down so as to permit a variation in the direc- 
tion of the stream. These tubes have no stop-cocks, but, by 
a very simple mechanism, close when they are lifted well 
up. Each meets at an acute angle the tube by which it 
draws up the carbolized water which is placed in the reser- 
voir in front. At the lower end of each of the immersed 



78 ANTISEPTIC SURGERY. 

tubes is a little sponge, which filters the liquid which passes 
into them. 

The spra}' is very fine, does not wet, as that furnished by 
most machines does, and covers a large area. The arrange- 
ment which gives two beaks instead of one I have long con- 
sidered very important, not because there is need of two 
simultaneous streams, but because we want to be able, when- 
ever one of the beaks becomes clogged in the course of the 
operation, to open the other immediately without moving the 
apparatus. Several manufacturers in England and elsewhere 
have since adopted the same arrangement. 

If the apparatus is started with a full boiler, it will go 
more than two hours uninterruptedly. It runs with a low 
pressure, but is tested at a very high one in order to avoid 
the danger of explosion. It is quite large enough, and yet is 
not very heavy. 

The wick of the lamp is sheathed in two metallic tubes, so 
arranged that the flame can be increased or diminished at 
pleasure. Thus, when the escape-tubes are closed, a very 
little heat can be furnished, just enough to maintain the 
pressure. The lamp is filled from the side. 

At the beginning of the daily visit, we fill the boiler with 
hot water, supply the reservoir with strong carbolic solution, 
screw on the stopper, and light the lamp. We carefully 
watch, and lower the beak when pressure is got up, or allow 
even more pressure than is absolutely necessary, lest it fall 
too rapidly and the stream be imperfect. 

If we expect to use the machine for a long time, and the 
pressure is very high, we may well lower the wick, and, after 
a few minutes, raise it again. 

Generally the stream of steam has a characteristic blue 
color when it pulverizes well ; and, by pinching the rubber 
suction-tube, its thorough performance can be assured. 




bfl 



80 ANTISEPTIC SURGERY. 

Great pains should be taken to keep the reservoir well 
supplied with carbolic solution. 

If there arise any indications of failure of the steam, the 
lamp should be instantly extinguished to avoid burning the 
boiler. However, by lifting it, after a little experience one 
can tell by its weight when the boiler is nearly empty, and 
then it should be replenished at once. For this purpose, the 
lamp being extinguished, the steam is let off by the valve and 
both the tubes, and then one can unscrew the stopper with- 
out danger of burning himself. In replenishing the boiler, 
only hot water should be used ; in this way we avoid ruining 
the boiler, pressure is got up much more quickly, and the 
consumption of alcohol is diminished. 

When we have finished using the apparatus, it is well to 
completely empty the boiler, that we may know exactly the 
quantity of water to put in the next time. 

The boiler of my spray-producer holds about a liter, the 
lamp about half a liter. 

If the apparatus is needed for a short dressing only, it is 
sufficient to half or even quarter fill the boiler : the less 
water there is, the sooner will the steam be generated. 

Some surgeons have thought it necessary to fill the atmos- 
phere of their amphitheatres with a thick cloud, others have 
set up costly high-pressure machines ; but I think my spray- 
producer suffices for all wants. It is placed upon a table at 
the distance of two meters from the field of operation, which 
it envelops in a cloud which neither obscures vision nor wets. 
Being constructed on the principles so ably expounded by 
Lister, it cannot fail to give satisfaction. 

Finally, it is worth while, in the interest of economy, to 
bear in mind that such a spray-producer is not only valuable 
for the special service it was designed to perform, but is of 
great use in making a spray for inhalation and in purifying 
and disinfecting the wards. 



AMERICAN SPRAY-PRODUCERS. 



81 



CODMAN &, SHURTLEFF, 
BOSTON 

c 




Among the spray-producers of American manufacture one 

of the most reliable is that 
represented in the accom- 
panying cut. It has a 
spherical boiler which is 
tested by a hydrostatic 
pressure of more than one 
hundred pounds to the 
square inch. The tubes 
are of brass, with plati- 
num nozzles, and can be 
readily removed and re- 
placed, so that tubes for 
lg * other than antiseptic pur- 

poses may be substituted. In the lower tube there is a 

clearer which is easily operated. The lamp-jacket confines 

the heat under the boiler 

and protects the flame from 

currents of air, but does not 

prevent a view of the flame. 

The lamp is provided with 

a flame-regulator and an 

extinguisher, which can be 

operated from the outside, 

and it can be replenished 

with alcohol safely while in 

operation. This apparatus 

is advertised to run between codman &. shurtleff, 

BOSTON. 

three and four hours with Ei g . 3. 

one filling of the boiler. It costs twenty-five dollars. 

A much cheaper, but quite efficient spray-producer is 
shown in Fig. 3. The essential points are substantially like 
those in the machine just described. The price of this is 
twelve dollars. 




82 



ANTISEPTIC SURGERY. 




Fig. 4. 




Dr. Weir's apparatus, 
pictured in Fig. 4, is a 
modification of Lister's, 
constructed to avoid the 
great cost of the latter, 
jj without sacrificing any 
^ necessary details. It is 
furnished for fifteen dol- 
lars. 

Another ingenious and 
inexpensive instrument 
is that devised by Dr. 
Hanks, and shown in 
Fig. 5. The spray can 
be projected at any 
angle. The antiseptic 
fluid is not drawn up by 
the force of the steam, 
but is allowed to flow down from the elevated tank, the 
force of the stream being regulated by a stop-cock. 



CHAPTER X. 

Catgut. — Its Uses as a Ligature, for Drainage, as a Suture, 
and in the plugging of bony cavities. 

One of the most remarkable points in the practice of Lister 
is the employment of carbolized catgut. This is certainly 
one of the important triumphs of surgery. 

As has been remarked previously, a foreign body in the 
tissues induces suppuration, if it is charged with germs ; but 
if it is aseptic, it may remain an indefinite time without 
exciting the formation of pus. 

At the outset, struck with the disadvantages of ligatures 
which needed to be discharged and which excited suppura- 
tion in the depths of wounds, Lister made experiments to 
determine the effects of ligatures impregnated with fermenti- 
cide substances, particularly of hemp or silk soaked in a 
concentrated solution of carbolic acid. 

Although the first results were favorable, Lister thought 
that, if he could find a substance which would unite with the 
tissues or even be absorbed into them, the result would be 
incomparably better. The idea then occurred to him to em- 
ploy catgut which had undergone fermenticide preparation, 
and, after a number of trials, he achieved success. This 
ligature has properties so valuable that it is necessary to 
detail the mode of preparation. 

Catgut is made, as is well known, from the intestines of the 
sheep. We select cords of various sizes as they are found 
in the market, and it is well to know that they should not be 
very old and dry, and that those made in some countries are 



84 ANTISEPTIC SURGERY. 

superior to those made in others. The most solid and resist- 
ant are made in France. 

In the condition in which we find it, the cord cannot stand 
the tying of a knot ; it will often break. Thus the prepara- 
tion which it receives gives it strength, and at the same time 
deprives it of germs. 

It is steeped for from four to six months in the following 
mixture : — 

Crystals of carbolic acid are dissolved in one tenth part 
their weight of water, and five parts of olive-oil are added, 
and the whole is intimately mixed. The cords are placed in 
this emulsion, where they first swell, soften, and become 
opaque. After some time the thread becomes firmer, trans- 
parent, and more solid. The knot made now is very strong, 
does not break like one in a cord which has not been 
prepared, and does not slip as it does when oil only has been 
used in the preparation. 

It is a very curious fact that if, instead of adding water to 
the carbolic acid, we dissolve it directly in the oil, the effect 
upon catgut soaked in it is totally different, for it becomes 
soft and slippery as soon as it is wet, and is of no use what- 
ever. 1 

Although a good deal of time is consumed in the process 

1 Lister devoted his inaugural address as president of the Clinical 
Society of London, on the 28th of January, 1881, to the subject of the 
catgut ligature, and gave the results of his experiments to find a method 
of preparation which should obviate the necessity of consuming so much 
time as the above plan requires, and still produce a trustworthy article. 
He recommends the following process : — 

Dissolve 1 part of chromic acid in 4,000 parts of distilled water, and 
add to the solution 200 parts of pure carbolic acid. Into this liquid im- 
mediately put catgut equal in weight to the carbolic acid. At the end of 
forty-eight hours, the gut is sufficiently prepared. Then it is removed 
from the solution, dried, and placed in one-to-five carbolic oil. It is then 
fit for use. 



CATGUT LIGATURES. 85 

of preparation, we get in return a thread which remains good 
indefinitely, it' it is kept immersed, and even may be said to 
improve. Thread thus prepared is in every respect fit to be 
left in the midst of the tissues. This substance possesses, in 
fact, the property both of remaining without injury, and of dis- 
appearing little by little. It seems that it identifies itself with 
the tissues, or is absorbed. Experiments upon animals have 
shown that, after a certain time, only the knot can be per- 
ceived and distinguished from the artery and the peripheral 
parts where the ligature was left. We thus see that this 
ligature, instead of provoking the process of elimination, the 
result of which is the decay of the thread, in no way irritates 
the parts where it is found. Instead of cutting, it supports 
them ; it sustains them at the first moment of the ligation, 
and will continue to do so for a long time. This result is 
obtained when the ligature has been placed at the extremity 
of a severed artery, as in a stump, and also when it has been 
put around an artery in its continuity. 

In a stump the ligature, being cut short, remains, and does 
not prevent union by first intention. Even if it has been put 
upon tissues particularly susceptible to external irritation, it 
is proved that they do not resent its presence. Lister has 
had occasion to close wounded veins with catgut sutures, and 
the stitches have not been thrown off. 

Keith, of Edinburgh, so well known as one of the most 
successful ovariotomists, told me that he constantly and freely 
used catgut ligatures in the peritoneal cavity, that he had 
thus left a considerable number of them at a time, and that 
no accident had ever happened in consequence, even before 
he employed the antiseptic method. Many others have fol- 
lowed his example, and I among them. 

I have already had a large experience with catgut, having 
employed it particularly as a ligature in every way, and it 



86 ANTISEPTIC SURGERY. 

has never failed to fulfil the promise of the theory ; and I 
insist upon this fact, — that one derives from it many other 
effects than that of a simple ligature in a wound. 

It strangles the tissues sufficiently to arrest bleeding and 
yet does not kill them, if the wound is kept aseptic. If it 
is poisoned, casting off of the ligature is common. 

For example, when one practises castration, he can ligate 
the cord en masse, close the wound with sutures, and the end 
of the cord will not be thrown off. In 1876 I operated at 
the Hdpital Necker for the removal of a very large sarcoma 
of the testicle, and in seventeen days the patient was com- 
pletely cured without the discharge of the ligature. 

In the operation for strangulated hernia I have a number 
of times tied the omentum in little parts, and then reduced 
it or left it in the wound. The portions of omentum which 
were thus constricted were not eliminated, and the rapid 
union of the lips of the wound was not interfered with. 
(An excellent method for omental hernia, founded upon this 
principle, has been published by Dr. Chiene.) 

This is the principle which has been applied by ovarioto- 
mists, who divide the pedicle into several parts, tie each with 
catgut, and drop it back into the abdomen. Some close the 
abdomen with the complete suture, others drain it, as in all 
operations by the Lister method. 

It is evident that the soft parts may be constricted by 
catgut ligature without mortifying. One reservation must 
be made, — the parts compressed must neither be too volumi- 
nous nor have been previously mortified. 

In one hernia operation I saw one ligature out of seven 
thrown off with a little tuft of omentum, and the final heal- 
ing was retarded some days. But here the last part of the 
dressing was not aseptic; and when the dressing is rigorously 
aseptic, this occurrence is not at all likely to take place. 






DISAPPEARANCE OF CATGUT. 87 

Catgut must necessarily be employed for the sutures, for 
it renders valuable service when used in certain condi- 
tions. But there is room for discussion as to these cases, 
on account of the lack of solidity and also the swelling of the 
thread. 

We know that the substance which forms catgut is rapidly 
absorbed in the tissues. Numerous experiments have been 
made on this point, and we now consider as utterly incorrect 
the view that there takes place a veritable organization of 
the animal cord, which begins by swelling and appropriating 
young elements, and then disappears from the midst of the 
tissues, leaving new vessels in the place which it occupied. 

Whatever may be the method of this disappearance, it is 
actually effected, and Chiene has derived from it his method 
of drainage so eminently favorable to the rapid union of 
wounds. 

Another application of catgut is in the arrest of hemorrhage 
at the bottom of osseous cavities which bleed freely. Lister 
has reported among others the following case: in trephining 
a skull in the median line he opened the superior longitudi- 
nal sinus. He crowded pieces of catgut into the hole made 
by the trephine until it was completely full, and the blood 
was stayed. The catgut disappeared gradually, and the 
patient recovered without accident. 

In the same manner we insert in the osseous canal after 
amputation a bunch of catgut to stop the bleeding, which 
being accomplished, the catgut is left in place, and no harm 
follows. 

In each of the special chapters the uses of catgut are men- 
tioned. It should be known that it may be employed like 
other threads ; when it is well prepared it is simple and easy 
to manage. I am in the habit of employing thread of quite 
large size, considering it useless to take the fine, as thread of 



88 



ANTISEPTIC SURGERY. 



any size disappears. I make three knots instead of two, to 
guard against the possible slipping of the second. 

I have described the manufacture of catgut with some 
minuteness, because the commercial article is often a medi- 
ocre product, made hastily, with cord of poor quality, without 
the addition of water to the oil, or without a lapse of time 
sufficient for its preparation. To this I attribute most of the 
objections falsely made to the employment of this very valu- 
able material. 



CHAPTER XL 

Influence of the Method upon the Phenomena of Repair. — 
The Absence of Suppuration. — The Beginnings of Experi- 
mentation. — Absence of Micro-organisms. 

We have considered the principles of the method and the 
details of the dressing. What are the results ? 

At first thought it would seem to be easy to decide this 
question by a reference to statistics. Of these we have 
already valuable elements, as will be seen in another chapter. 
But the method is quite new ; it has been misapplied and 
perverted by many who have scant knowledge of it, and yet 
publish in its name results which are barely improvements on 
those of other methods ; and even the method of the last 
years is much surer than that of a decade ago, and the figures 
of the former period are not to be compared with those of 
recent times. From this it is evident that the data are insuffi- 
cient, and besides one can easily make whatever he wishes of 
statistical figures. 

But we have more precious elements, of which the first is 
the unanimous opinion of those who have thoroughly adopted 
the practice of antiseptic surgery. There is but one voice 
concerning the general progress of surgery; every one says, — 

" The ranks of my patients were formerly decimated by 
surgical complications, especially by purulent infection. I 
have seen these complications disappear from my wards. Not 
only to-day do I no longer fear purulent infection, septicae- 
mia, but I practise as I choose all the operations which are 
most hazardous to patients, — upon the bones, articulations, 

7 



90 ANTISEPTIC SURGERY. 

and veins, — and I see no harm result. Hospitalism is a word 
which has lost its meaning. It gives so little inquietude 
that one may defy it in his wards." 

These statements, coming from eminent men of large ex- 
perience, are calculated to excite us, but it would take a long 
time to convince us of the reality of these marvellous results 
and of much other progress, if it were not easy at the first 
trial to comprehend, avouch for, and even explain them by 
the study of the phenomena of repair. We no longer seek 
an explanation in the enthusiasm of the inventor or his disci- 
ples and in the allurement of novelty. 

Careful observation made in our hospitals, as well as in 
Edinburgh, London, Denmark, Germany, indeed, all over the 
world, prove to the most incredulous the marvellous change 
in the phenomena of repair, which is in a way the criterion 
of the worth of the method. 



The phenomena of repair. 

From the first essays of the method, the observer is greatly 
impressed with the totally new progress of the reparative pro- 
cess. Formerly, in all wounds of any importance, the follow- 
ing phenomena were, in varying degrees, observed constantly : 
change in the appearance of wounds and the surrounding 
parts, swelling of the edges, suppuration, great tenderness, 
tension, and pain ; at the same time more or less severe trau- 
matic fever. 

If the surface of the wound was extensive, suppuration 
was abundant, and the dressings always exhaled a more or 
less fetid odor, particularly if the fluids had been retained a 
little while. If clots of blood had accumulated in the 
wound, after remaining a time they were detached and formed 
a magma, which was fetid .from the suppuration which at- 






RAPIDITY OF REPAIR. 91 

tended its removal. Fragments were left behind which seri- 
ously interfered with repair and invited complication. 

Then the period of inflammation passed away, suppuration 
diminished, granulations sprang up at all points where union 
by first intention had not taken place. Cicatrization was ob- 
tained only with more or less lengthy suppuration, involving 
either a part or the whole of the wound, with divers varia- 
tions during the continuance of the reparative process. 

But with the antiseptic dressing nothing is the same. All 
the parts which are brought together by suture unite. From 
the depths of the wound drains off abundant serum, blackish 
at first, but later only turbid or yellowish. This discharge 
diminishes little by little, and soon becomes insignificant. 

Around the wound there is no swelling or redness. On 
the eighth day a stump presents the aspect and color which 
were observed on the first. 

If clots of blood have been enclosed under the flaps or 
between the lips of the wound, instead of disintegrating, of 
provoking suppuration, of hindering union, they take part in 
the phenomena of repair. Their surface takes on a very 
characteristic grayish tint. They adhere to the lips of the 
wound, some effort is necessary to detach them, and, after 
some days, if they are scratched, the surface bleeds, new ves- 
sels having formed in them. According to Professor Lister, 
they become organized where they lie. Surely, the operator 
cannot doubt their presence in the wound. 

In the dressing there are no infecting fluids, no bad odor. 
At no time after their application do the pieces of dressing 
emit any odor but that which is characteristic of the resin 
and carbolic acid which they contain. 

The phenomena of repair in all tissues, especially in those 
far below the surface, are accomplished with inconceivable 
rapidity. 



92 ANTISEPTIC SURGERY. 

I have observed this so many times that I am surprised 
when this rapidity does not obtain ; but I was much struck 
in seeing at the Edinburgh Infirmary, in 1875, a wound 
twenty centimeters long, from the ablation of a breast, healed 
in nineteen days. Furthermore, a woman in whom the ex- 
ternal iliac had been ligatured was well in less than three 
weeks. At the same time, Lister told me of a resection of 
the knee, with complete cicatrization in fifteen days. Analo- 
gous facts are common to-day. 

We used to see wounds repair differently, according to 
the tissues which were involved. Now, whether the wound 
involves bone, serous membranes, vessels, or areolar tissue, 
repair occurs with remarkable uniformity. 

In all these wounds we leave great numbers of ligatures, 
which do not become detached, but become incorporated 
with the tissues, and support instead of destroying them. 

Traumatic fever is generally of slight importance, being 
reduced to its minimum ; but it usually is present, though 
appreciable only with the thermometer. There is very little 
reaction. 

All this has an important bearing on the theory of trau- 
matic fever. I have expressed the view that nothing sup- 
ports the idea that traumatic fever has a septicemic origin. 
It results from a local irritation, reacting more or less upon 
the economy through the nervous system. Putrid liquids 
accumulate on the surface of a wound and irritate it ; remove 
them and irritation diminishes, the fever subsides. It does 
not disappear completely, because there remain some parts 
which are irritated by the air, the dressings, and the dead 
elements which are thrown off. 

If it were true that traumatic fever depended upon poison- 
ing by putrid materials, it would not exist when the wound 
was absolutely aseptic. I have elsewhere presented this ar- 



ABSENCE OF SUPPURATION. 93 

gument, and many others, which seem to me equally con- 
vincing against the septicemic origin of traumatic fever. I 
was very happy to find my opinion in conformity with that of 
Professor Lister. 

I have already pointed out a remarkable resemblance be- 
tween the thermic results of the dressing of Lister and those 
of the wadded dressing of Alphonse Guerin, which also di- 
minishes the intensity of the traumatic fever, and said: 
" Reduce to their minimum the phenomena of elimination, 
mortification, and local irritation, and you will diminish to its 
minimum traumatic fever." 

That which is, indeed, the most characteristic point in the 
method of Lister is the reduction to a minimum of the phe- 
nomena of elimination. 

Not only the united lips of a wound are consolidated, but 
the walls of a traumatic cavity come together and unite under 
very slight pressure ; and suppuration, which is always pres- 
ent when the cavities of wounds heal by granulation, does 
not take place. Even an abscess cavity does not suppurate. 

The liquid which drains from the wounds is so different 
from common, laudable pus that the two should not be con- 
founded. That which shows this method of repair to be the 
most perfect is the absence of waste of young cells, which, in 
wounds treated by ordinary methods, are thrown off in great 
numbers. 

The wound under the antiseptic dressing, says Lister, gives 
no pus. At first it discharges a sanguinolent liquid, then a 
darkish serum, then serum which is either transparent or 
cloudy. There are in it granular corpuscles, but not the 
masses of well-formed globules which characterize ordinary 
pus. In this fluid the globules are infrequent, modified, 
with no definite characteristics. 

However, to the naked eye, the appearance of the liquid is 



94 ANTISEPTIC SURGERY. 

not always the same : sometimes it is viscid, and resembles 
synovia : at other times it is yellowish, and looks a little more 
like pus, and may fill up the drainage tubes. 

If the wound is irritated and badly drained, the liquid, 
always scanty, is even more like laudable pus, without its 
creamy consistency. If the cause of the irritation is removed 
in the course of the day, the cloudy serum reappears. This 
is seen in a recess of a badly protected wound, about a stitch 
which is too tight, in a cavity with too narrow an opening of 
exit. It should be watched for and remedied immediately. 

But if, in the absence of these causes, you see on the sur- 
face of a wound a layer of true pus, creamy and abundant, 
you may be sure that germs have penetrated and the dress- 
ing is infected. The patient is not necessarily injured seri- 
ously, but he is endangered, and he will recover by the pro- 
cess of suppurative reparation, the ideal of ancient surgery. 
You may be sure, then, that true antiseptic surgery has not 
been accomplished. 

The more nearly the phenomena of repair approach the 
type we have indicated, the simpler is reunion ; and it is in 
these cases that we see clots at the bottom of a wound not 
disintegrating, but taking a gray tint, contracting a little, and 
becoming penetrated with vessels. If they themselves do 
not, properly speaking, organize, they contribute to repair ; 
they serve as a woof for the weaving in of the neighboring 
vessels, which put out buds, and soon their substance is vas- 
cular. Their presence assists repair. Lister counts so much 
upon this phenomenon that, when he scoops out great cavities 
in bone which cannot collapse, he scrapes the fleshy granula- 
tions in the vicinity in order to fill up the osseous cavity with 
clots ; because, when he does so, living tissues occupy it much 
more quickly, and healing is greatly accelerated. 

The absence of the phenomena of irritation during repair 



FREEDOM FROM SUFFERING. 95 

permits each element to live in the midst of a wound as well 
as, perhaps better than, in the depths of tissues which have 
not been uncovered. This is what explains how repair is so 
rapid, so exempt from complications, in the case of serous 
membranes and viscera, which are prone to inflame. One 
operates in conditions more favorable, certainly, than those 
of subcutaneous surgery. 

It is so true that inflammation does not occur, that the few 
operations where it is needed are, in a measure, incompatible 
with antiseptic surgery. In the operations for pseudarthrosis, 
the resections produce almost no formation of callus, and the 
antiseptic method must be abandoned after a few days in 
order to obtain irritation enough to provoke the required 
exudation. 

Repair is singularly regular. With the old surgery it 
could be said that each new wound had its own physiog- 
nomy ; that wounds differed absolutely in appearance and 
progress, according to the tissues involved. Here, all are 
alike : the same pallor of the tissues, the same constant 
union, the same non-purulent discharges, with some differ- 
ences as regards the amount of liquid and the greater or less 
duration of drainage, according to the size of the traumatic 
surfaces. But all points in the wound have the same aspect. 
The uncovered parts have a certain grayish tint, which is not 
particularly pleasing to the eye ; and they preserve this hue 
until healing is completed, if they are not molested with 
untimely friction. 

One of the most fortunate phenomena is the freedom from 
suffering. Partly on account of the anaesthetic action of the 
carbolic acid, much more because of the absence of irritation, 
the spontaneous pain is slight, and contact with the wound is 
not distressing. The patients do not complain at having 
stumps and immense traumatic surfaces dressed. If there is 



96 ANTISEPTIC SURGERY. 

pain before the operation, the sedation is marvellous ; and we 
may say that one of the most striking characteristics of ser- 
vices in which the antiseptic method is employed is the ap- 
pearance of the patients, who, free from fever and pain, eat 
and sleep and recuperate their powers in perfect quietude. 

Local complications are absent. There is repair without 
pus, without fetor, with reduced fever, without pain, without 
exhaustion of the wounded. There are no general complica- 
tions, as we shall see in the following chapter. The most 
fortunate surgeons used to consider erysipelas and septicae- 
mia possible : certain operations predisposed to these dis- 
eases to such an extent that they were specially feared. But 
now, whatever the man, the medium, or the operation, com- 
plications have disappeared ; for even erysipelas, which some- 
times shows itself, is shorn of its grave character. 

Just as the wounds present a very remarkable appearance, 
the scars also are extremely interesting. They are neat, reg- 
ular, and linear. Stumps which have not suppurated are 
supple. There are no cicatricial adhesions, retractions, or 
indurations. In regions which are accessible to inspection, 
operations leave scarcely a trace. 

What I observed in Professor Lister's service I have seen 
in my own ; and 1 have been deeply impressed with the fact 
that I obtained the same results immediately. I was cer- 
tainly far behind the perfection of the master ; and yet, from 
the beginning, I found the same modification of the processes 
of repair. I think it very important to put this fact on rec- 
ord, and for this reason I revive to-day the history of the first 
operations which I made, in 1875 and 1876, in the temporary 
hospital, with a strict method. These operations were va- 
ried, and in all I obtained union, in all the surgical fever was 
slight, in none was there a discharge of true pus. I may be 
allowed to cite the amputation of a leg at the upper third, 



ILLUSTRATIVE CASES. 97 

absolutely cicatrized, epidermis included, in twenty-four days. 
There was a large clot in the stump, and yet repair was not 
impeded. 

An enormous myxoma of the parotid, larger than a tur- 
key's egg, in a man of twenty-eight years of age. On the 
fifteenth day there was a little epidermic ulceration. On the 
eighteenth day I showed him to the Surgical Society, abso- 
lutely healed. There never was a drop of pus or puriform 
liquid in the wound, only^ turbid serum. His temperature 
did not exceed 38° C. 

A lipoma under the scalp was removed from a man of fifty 
years. It had the dimensions of a hen's egg, and lay in the 
left fronto-parietal region. A great deal of blood was dis- 
charged into the cavity after the suture was made ; but in 
spite of this, there was no suppuration, and cicatrization was 
complete in nine days. 

Trephining of the greater trochanter, attacked with osteitis 
in a man of forty-eight, who presented immense fistulas, com- 
mencing at the iliac crest and descending beneath the tro- 
chanter. The fistulas were cleansed and injected with chloride 
of zinc ; the very extensive wound of the operation was closed 
first, and all the great fistulas were closed in a month. The 
dressing was then omitted, and the patient, who had been 
confined to his bed for eight months, with suffering so intense 
as to make walking impossible, stepped off without difficulty. 
I made him go to bed again, because I found that one of the 
numerous fistulas low down had been neglected. It was 
superficial, but pretty long and well-organized, for I made 
carbolic injections without success. I decided, after some 
days, to cleanse this fistula by the proceeding previously de- 
scribed, to make a counter-opening, and put in a drain. In 
a few days it was perfectly closed, and the patient was cured, 
a result which I verified eight months afterwards. 



y» ANTISEPTIC SURGERY. 

This man had a long and interesting history. He suffered 
continually without respite up to the day of operation. I 
found nothing in the joint to explain this pain and his in- 
ability to walk. The greater trochanter was a little increased 
in size and tender on pressure. A multitude of constantly 
suppurating fistulse had followed as many abscesses, bat the 
bone could be reached at only one point. To-day all the 
fistulas are closed, and walking occasions no pain. 

In this case I made a free incision, and removed a large 
prominence of the trochanter, the tissue being soft but not 
carious. Excepting the point where two large drains passed, 
the whole wound united. Two very firm sutures provoked 
around them the formation of four or five drops of pus, 
which I evacuated. The great wound never gave any dis- 
charge but serum, at first dirty, then yellowish, and a little 
viscid after some days. The traumatic fever was insignifi- 
cant, the temperature never reaching 38° C, and in a month 
everything was cicatrized. This large wound, complicated 
with traumatism of bone, behaved like the wound made in 
the removal of the parotid tumor, which I have just re- 
ported. 

Besides the major operations made in the first six months 
of my experience, I reported a number of others of minor im- 
portance, not only in the way of congratulating myself on 
having seen them escape so-called hospital complications, but 
also to note that the same mode of repair is shown in small as 
in large operations. 

Two amputations in the same patient, one of the great toe, 
the other of the second, rapidly and perfectly healed, in spite 
of a diseased and injured skin, and the fact that the ligatures 
were left in the wound. 

I have practised upon two patients denudation of veins for 
varix, after the manner of Rigaud, which consists in exposing 



OPERATION FOR VARIX. 99 

a large venous trunk and isolating it upon a foreign body, 
and I was able to note from the very first entire absence of 
reaction. But I was especially struck at seeing that these 
isolated veins, lifted up on sounds, did not die under the 
dressing. The first, which was slender, was well denuded, 
and placed upon a rubber tube. I supposed, at the first 
dressing, that the tube would not sufficiently hold the vein, 
and therefore substituted for it a gum sound. The vein did 
not break ; a little blood was effused around it. At the end 
of a fortnight, tired out, I removed the sound. The wound 
cicatrized rapidly, and when the patient, cured of his ulcer, 
got up, I saw with regret that the vein was perfectly 
pervious. 

In the second patient, finding a large, thickened vein, and 
foreseeing the same inconvenience, I denuded it extensively 
and raised it up on two sounds. It died no more than the 
other. The effusion filled up the wound around the vein, 
which I liberated at the expiration of twelve days. Never- 
theless, the vein was obliterated. The patient, rapidly cured 
of his ulcer, walked off, provided with a cloth stocking and 
feeling very comfortable. 

In these tw T o cases it seemed that the dressing, which al- 
lowed the tissues to retain their maximum of vitality, pre- 
vented mortification of the walls of the veins. Therefore, 
recognizing this absence of reaction, this ease of operation 
upon the veins, I have devised another operative procedure, 
for I never had more than moderate confidence in the harm- 
lessness of the original procedure without the Lister spray. 
Rigaud, having thrice opened veins, lost three patients by 
purulent infection. 

My operation is vastly more simple, much more rapid in its 
healing, and sure to effect obliteration. It consists in tying 
the great venous trunks with catgut, which is left in the 



100 ANTISEPTIC SURGERY. 

wound. I have as yet -performed this but once, but it seems 
destined to give the best results. It is much easier than 
Rigaud's and is surely infinitely less dangerous. 

I have made yet other operations with excellent results — 
enucleation of the eye, which I dressed with boracic acid ; ex- 
tirpation of a neuroma in the stump of a fore-arm. 

In another class of cases I have had capital proof of the 
influence of the method, as illustrated in the opening of an 
abscess of the neck, under the sterno-mastoid, following 
angina. The patient, who was in a dangerous condition, 
being chloroformed, I opened the abscess with antiseptic pre- 
cautions, and injected the cavity with weak carbolic solution, 
afterwards using the strong. In eight days, a great purulent 
sac which had been freely opened was completely closed, and 
after the primary evacuation there was scarcely any discharge 
of pus. 

In the first edition of this book I reported the preceding 
cases, and I repeat the record now in order to show exactly 
what every surgeon can accomplish in his first attempt by 
strict observance of the method. And yet my conditions 
were unfavorable, my assistants were inexperienced, I was 
obliged to disturb myself with pharmaceutical details ; but I 
contributed an element of appreciation which was of value. 
The service of the temporary hospital in which I had this 
experience contained forty-five beds in an old building badly 
located, of the healthfulness of which I never had a good 
opinion. During these six months there were six cases of 
erysipelas, but not one occurred in a patient who had the 
antiseptic dressing. Three of them were brought in ; three 
broke out in the wards, — one in a patient who had a little 
wound of the head without any dressing, the two others in 
men who had ulcers of the leg. One of these had a severe 
erysipelas which started up in an almost cicatrized wound ; 



NO WOUND COMPLICATIONS. 101 

the other, with an immense ulcer of the leg, had erysipelas in 
the face, and died. 

Thus it will be seen that the surroundings were far from 
favorable for operations upon the veins or the scalp. 

In the four years which have slipped away since then I 
have had a large experience. I have made my operations in 
one after another of the Paris hospitals, some of which are 
not of the best. I did a large amount of work in the Lariboi- 
siere, and also in the Keeker. I have operated, or had 
charge of the operations for the most part, in the following 
hospitals : Pitie\ H6tel-Dieu, Beaujon, Maison de Sante, En- 
fants Malades, Sainte-Eugenie, Bicetre, Saltpetri£re, Mater- 
nity. Everywhere the results have been the same. Some of 
the surgeons have continued to employ the method, more or 
less rigorously — Professors Guyon, Verneuil, Panas, MM. 
de Saint-Germain, Le Dentu, Terrier, Perrier, and many 
others. Even those who have not been, in my opinion, suffi- 
ciently rigorous, have made such progress that their surgery 
has changed its appearance. Those who have been more 
strict have had results identical with my own. 

In spite of the importance of this practice, I present no 
statistics, for I consider mine insufficient. All that I can say 
is that, when the method has been rigorously pursued, I have 
not had a single case of wound complication, either in an 
operation patient or in one who has been seriously injured. 
I have seen neither erysipelas nor purulent infection, and I 
have dared to do operations which no one before has ven- 
tured in France ; and when I have applied the method to 
some wounded men and not to others, it has been used in the 
most serious of the cases. 

I may remark here that, in describing the indications for 
the principal operations, I shall report cases from my own 
practice. 



102 ANTISEPTIC SURGERY. 

I must not close this chapter without saying a word on a 
most important question. In the midst of the laborious pur- 
suit of antiseptic surgery, I have had little leisure for study- 
ing the capital theoretic question, of noticing the presence or 
absence of living beings in protected wounds. Having no 
confidence in my personal competence in this respect, I will 
not report my investigations. I have made a few investiga- 
tions in ordinary conditions, with negative results ; but this 
small number of observations is not a sufficient foundation 
for an opinion. 

Lister, a singularly competent and strict observer, found 
none of the organisms of putrefaction in the fluids of his own 
dressings. His pupils also have searched for the micro-organ- 
isms which characterize putrefaction, and have not succeeded 
in finding them. I am aware that some other authors, par- 
ticularly Ranke, are said to have found them in the best- 
made dressings ; but even in these cases, the micro-organisms 
did not resemble those of common wounds, either in form, 
number, or activity. 

On the whole we may assert, upon the authority of compe- 
tent observers, that microbes are absent in wounds treated in 
this manner. There is still need of careful observations to 
rigorously and absolutely demonstrate their absence ; but 
their presence has been affirmed, rather than demonstrated, 
by the other investigators, who have found them to be 
infrequent and peculiar. 

Are we to believe, with those who have found micro- 
organisms under the dressing, that their conditions of ex- 
istence are so profoundly modified that they have become 
innocent and incapable of doing harm? This idea is defensi- 
ble. The history of these creatures is not yet written ; their 
varieties may be infinite, and we scarcely know those condi- 
tions of their existence which are the most simple and the 



MICROSCOPIC OBSERVATIONS. 103 

easiest to observe. Investigators of high competence must 
decide at last as to the theory and microscopic observa- 
tions. 

One is apt to think that it is sufficient to take a look in 
order to judge ; but it is necessary to know how to look, and 
this is a very difficult matter. 



CHAPTER XII. 

General Results of the Dressings. — Wound Complications. — 
Some Figures. — Lister. — Saxtorph. — Volkmann. 

The attentive reader of the preceding chapter should be 
able to foresee the immediate and remote consequences of the 
application of the method. If it is true that almost the en- 
tire traumatic surface is immediately closed, that healing is 
most rapid, that the phenomena of elimination are reduced to 
a minimum, that the phenomena of putrefaction are sup- 
pressed, it is extremely probable that the accidents of wounds 
will be infinitely rare. This, in fact, is what all affirm who 
have tried the method in a serious way. The modification is 
most striking in the case of purulent infection, pyaemia. We 
see it disappear at once from certain services where it had 
been constantly observed ; and this was, according to Lister, 
the first benefit of the application of the method in Glasgow. 
Hospital gangrene also disappeared, as has been remarked in 
a number of institutions where it was previously endemic. 

Quite naturally, prolonged suppurations and putrid infec- 
tion are suppressed. Erysipelas is perhaps less influenced, for 
it is sometimes observed in spite of the dressing ; but, never- 
theless, it is infinitely less frequent than with other methods, 
and, as authors say, it is less alarming in its manifestations, 
even in times when it is epidemic. 

These results are not obtained merely by a few advocates 
of the method, which has made, in spite of active opposition, 
many more converts than can be enumerated. It has given 
the same results in every place where it has been adopted. 



LISTER IN GLASGOW. 105 

And, in this connection, it is only fair to note that the pub- 
lished statistics in many countries and hospitals of the more 
or less fortunate modifications which have been made are far 
from giving an idea of the success which is attained by the 
rigorous method. 

The complete transformation of surgery is evident. Doubt- 
less there are many who deny the light ; but none who care- 
fully study the published facts or well-conducted services can 
long resist. ^ 

Is it necessary, in order to judge of these results, to gather 
into a common statistical table all the facts which have been 
reported, and add them up ? That would give the most 
erroneous idea possible. The method is too new to be tested 
in that manner. 

Unlike figures should not be reckoned together ; and if, 
nevertheless, I do so in this chapter, it is for the purpose of 
showing how the same surgeon, in the same service and at 
the same period, has abruptly modified his surgery. 

The first and most striking example is that taken from the 
practice of Lister. He inaugurated antiseptic surgery in 
Glasgow in a hospital situated in the midst of emanations 
from a graveyard so crammed with bodies that they were 
hardly covered with earth. The windows of the wards for 
the wounded were most directly exposed to these effluvia. 
No change was made in the situation of this hospital, which 
was notorious for its surgical complications. 

Lister compares his results before the antiseptic period with 
those obtained during it. The method was in its infancy, its 
success was far from being complete ; and yet one can easily 
see the first transformations which were wrought in the midst 
of circumstances which, as he has vividly shown, comprised 
all the special causes of unhealthfulness. 

Being unable to find the records of three consecutive years 



106 ANTISEPTIC SURGERY. 

preceding the antiseptic period, he takes only two years. The 
antiseptic period includes 1867, 1868, and 1869. 

In the first period there were thirty-five large amputations, 
with sixteen deaths ; in the second, forty amputations, with 
only six deaths. Thus the mortality for amputations was 
reduced from forty-five to fifteen per cent. 

The result was curious, especially in view of the fact that 
the mortality after the least of these large operations was 
always due to the dominant influence of hospitalism. Thus, 
in the first period there were twelve amputations of the upper 
extremity, with six deaths ; in the second, twelve amputations 
of the upper extremity, with only one death, and this was in 
the case of a boy who was operated on in spite of the mani- 
fest existence of purulent infection. 

But this was only in the beginning of his method, and the 
progress has been immense since then. In Edinburgh he 
had only one case of purulent infection in six years, this 
following ablation of the breast ; he had in the same period 
not a case of hospital gangrene. As regards erysipelas, it 
was very rare, was less severe, and often was situated far 
from the wound. He had in his wards only two cases of 
tetanus, and both of these were in patients who had putrefy- 
ing wounds. 

In the least healthy wards, Lister for four years suspended 
the annual washing which had been customary up to that 
time. He brought in extra beds ; there were sometimes as 
many as three or four children in a bed. He often had 
seventy patients for fifty-five beds. The cleanliness of the 
patients was only relative. Aside from antiseptic neatness, 
they were dirty enough. Think of dressings remaining in 
place six or eight days. " From the sesthetic point of view 
they were foul, from the surgical they were clean." 

After his removal to London, Professor Lister continued to 



saxtorph's statistics. 107 

observe the same very happy results. He reserves all these 
facts for a general statistical table, when they have become 
very numerous ; but it is proper to state that the success of 
his practice has in no respect diminished. 

Again, we find the same results in the practice of Saxtorph, 
of Copenhagen, one of the first in Europe to employ the 
Lister method in a great hospital service, and an ardent advo- 
cate of it. 

In a hospital whose insalubrity every now and then became 
so marked that purulent infection swept off his patients, even 
after an amputation of a finger, he made in 1876 the follow- 
ing operations, the statistics of which he himself furnished 
me with : — 

Eleven resections of the knee, three deaths. 

Nineteen amputations of the thigh, six deaths. 

Fifteen resections of the hip, six deaths. 

Eight resections of the wrist, two deaths. 

Seven resections of the elbow, one death. 

Six resections of the shoulder, three deaths. 

Ten extractions of foreign bodies from joints, freely laid 
open, one death. 

Twenty-two Syme's amputations of the foot, seven deaths. 

Eleven extirpations of the calcaneum, four deaths. 

But this was only the commencement, the transition from 
a state of insalubrity to a condition of health, with all the 
gropings of a beginner in a method ; and his results are very 
much nearer perfection to-day. 

Saxtorph has not reported all his statistics, the figures of 
which would be enormous, but he has informed us of the 
sum total of his results after resections, and especial attention 
is asked to the teaching of this brief statement. 

It is easy to follow the improvement in results, step by 
step, in exact proportion to the exactness of the application 



108 ANTISEPTIC SURGERY. 

of the antiseptic method. A mere glance at the figures is 
enough to show that deaths became very rare. 

One hundred cases of resection are recorded — shoulder, 
elbow, wrist, hip, knee, ankle, — and two thirds are of the 
hip and knee. 

The total mortality is thirty-three, that is, thirty-three per 
.cent. 

But although the author early brought the method into 
Denmark, his cases at first were treated without the Lister 
dressing or with a very imperfect dressing, and here are the 
figures which they give : — 

Before 1873, fifteen resections with nine deaths — sixty 
per cent, of mortality. 

Then the method began to make its beneficence felt, and 
the sum total before 1877 was seventy-six resections, with 
thirty- two deaths — a mortality of forty- two per cent. 

After 1876 the method was much more rigorously applied, 
and since 1877 thirty-four cases, the greater part of which 
were large resections (fifteen of the hip and twelve of the 
knee), gave only five deaths — a mortality of but seventeen 
per cent. 

" In short," says Saxtorph, " I have made great progress. 
Since 1877 I have constructed a spray-producer which ena- 
bles me to be more rigorous, more exact ; and since then I 
have made twenty-four large resections of joints, almost all 
of the knee or elbow, and I have lost only one patient, and 
that one by tetanus, which gives but a trifle more than four 
per cent, of deaths, that is to say, about a fourteenth part of 
the mortality of the first years." 

As regards the patients who recover, the results are incom- 
parably superior, the functions of their limbs being much 
more surely restored and the absence of complications re- 
markable. 



THE HOSPITAL AT HALLE. 109 

With such results, one can easily understand that Saxtorph 
writes me as follows : — 

" There is nobod}^ I think, in Denmark who does not use 
the Lister dressing in his operations. As for me, I would 
give up the practice of surgery, if I could no longer operate 
antiseptically." 

The most curious of all the personal statistics are those of 
Volkmann, of Halle, whose surgery passed from the most 
wretched results of hospitalism which can be imagined to the 
most perfect security that one has a right to wish for. 

He had a deplorable induction, into a hospital manifestly 
infected. At the time when he began to employ the method, 
Volkmann, in utter despair of their sanitary state, was on the 
point of demanding the closure of his wards. It would seem 
that their aspect was not enchanting if we may believe the 
description of Dr. Schuppert, of New Orleans, who made 
very careful observations of the antiseptic method throughout 
Germany. He says : — 

" It is an old, miserable building, tumbling into ruins, 
situated in the midst of a dense population, surrounded by 
narrow, dark, and filthy streets. This hospital, if such it may 
be called, has no other means of ventilation than that by 
infrequent and narrow windows." — JV. 0. Medical and Sur- 
gical Journal, March, 1876. 

The results were quite in harmony with the appearance of 
the hospital ; purulent infection and all the complications of 
wounds raged with a violence previously unheard of, and, to 
cite only one class of wounds particularly, the author reports 
that in 1872-73 he attempted to save sixteen cases of com- 
pound fracture, and twelve of them rapidly succumbed to 
pyaemia. 

In 1873, Volkmann in despair made a trial of the Lister 
dressing in all its strictness, and from that time to 1877, he 



110 ANTISEPTIC SURGERY. 

employed conservative treatment in seventy-five complicated 
fractures in seventy-three patients, without a case of death. 
And all his surgery abruptly assumed an aspect of which 
some idea may be obtained from the brief report which he 
made to the Congress of German Surgeons, in April, 1877, 
the essential points of which are subjoined. 



Operations performed in the Clinic at Halle from the 1st of March, 1874, to 
the 1st of March, 1877. Ten thousand cases, of which one thousand 
were large operations or grave injuries. 

Amputations and Disarticulations. 

Simple Oases. 

Disarticulation of shoulder, four. One death after four 
hours. 

Amputation of arm, fourteen. No death. 

Amputation of fore-arm, twenty-three. No, death. 

Disarticulation of wrist, three. No death. 

Disarticulation of thigh, two. One death after four hours. 

Amputation of thigh, forty-two. One death after twenty- 
four hours. 

Amputation of leg, twenty-five. One death from erysipelas. 

Partial amputation of foot, forty-two. No death. 

Complicated Cases. 

Double amputation, nine. Two deaths, both patients hav- 
ing suffered amputation of both thighs. 

Serious multiple lesions, six. Six deaths ; traumatism with 
or without operation ; death in a few hours. 

Operations in the course of septicaemia, fifteen. Eight 
deaths. 



VOLKMANN S RESULTS. Ill 

Deaths from intercurrent maladies : — 

A man of sixty, whose thigh was amputated, died of de- 
lirium tremens. 

A tuberculous girl of sixteen died of pneumonia. 

A woman of twenty-four had the humerus amputated for 
phlegmon. Abortion followed, and she died of puerperal 
fever. 

In these cases, cicatrization was almost complete at death. 

The total of the largeu operations was one hundred and 
seventy-two, with twenty-three deaths — a little more than 
thirteen per cent. 

Resections. 

Uncomplicated Cases. 

Shoulder, seven ; elbow, two ; wrist, two. All cured. 

Hip, forty-eight. Four deaths, two of them after three 
months, the others in children aged nine months and two and 
a half years respectively. 

Knee, twenty-one. One death from tuberculous meningitis. 

Tibio-tarsal articulation, five. No death. 

Complicated Cases. 

Four in patients already suffering from septicaemia or 
pyaemia. Four deaths. 

Resections in the continuity of limbs : for false joint, nine ; 
for vicious callus, one. No death. 

Osteotomy ; fifty operations on thirty-eight patients. One 
death from hemorrhage in a bleeder. 

Operations on the breast : one hundred and nineteen on 
one hundred and ten patients. Six deaths : two of erysipelas, 
one arising from neglected dressing, the other from an eschar 



112 ANTISEPTIC SURGERY. 

on the sacrum ; one of shock ; two of exhaustion ; one of 
malignant pustule, communicated by the catgut. 

Incisions of hydroceles, forty-five, cases. No accidents. 

Complicated fractures treated conservatively, seventy-five 
in seventy-three patients. No death. 

Secondary amputations : thigh, one ; knee, four ; leg, forty- 
two ; arm, six ; elbow, five ; fore-arm, fifteen. No death. 

During this period of three years, there was not a case of 
purulent infection excepting such as existed on admission to 
the hospital. 

There were three or four cases of erysipelas in patients 
treated antiseptically, and some others in the non- antiseptic. 

From these statistics it is worth while to select a few which 
are really remarkable and very important. For example, 
Volkmann reports resections of the shoulder cured in fifteen 
days ; a resection of the elbow healed without pus in nine- 
teen days ; one of the hip on the ninth day without a drop of 
pus ; and one of the knee in a child of nine years, having 
caries with luxation and a large abscess, uniting without sup- 
puration. A month after the operation, the wound being 
completely healed, the child was walking about without a 
stick, his limb being supported by a splint. The bone tissue 
was so soft that it was cut with a knife. 

A man of forty-five years, who had suffered disarticulation 
of the thigh on account of a myxolipoma sixty centimeters in 
diameter, had his wound completely healed in ten days, ex- 
cepting the track of the tubes. 

A woman, aged eighty-four, recovered from amputation of 
the thigh, necessitated by an injury. 

A patient, from whose back a fibro-sarcoma measuring 
twenty-five centimeters in diameter was removed, left the 
hospital on the fourteenth day. 

I hardly know where to end my recital of these curious 



UNIVERSAL SUCCESS. 113 

examples of rapid repair, but I must add the remarkable ex- 
perience which Dr. Auguste Reverdin reports to me, of a 
patient both of whose feet were amputated by the Pirogoff 
method, six weeks intervening between the operations. The 
first was completely healed in fifteen days, the second in 
seventeen. 

In describing the antiseptic surgery of Volkmann, I should 
have said that his practice does not differ from that of Lister. 
He is rather more inclined i;o employ compression above the 
dressing. In places where it is difficult to accurately apply 
the dressing, he often completes it with salicylic wadding. 

I may add that Volkmann, to a much greater extent than 
Lister, employs irrigation with the strong solution, which he 
pours out from watering-pots lavishly in every direction in 
his amphitheatre. 

At the present time the surgeons who have adopted the 
method are innumerable ; but we must make mention of our 
colleague, Jules Bceckel, of Strasburg, and Nussbaum, of 
Munich ; and we could give the names of English, German, 
Danish, Dutch, Austrian, Swiss, Italian, Russian, and French 
surgeons who have successfully practised Listerism. 

I have already said what my results have been with anti- 
septic surgery in the hospitals of Paris ; and yet I desire to 
repeat that I have made a great many capital operations with- 
out encountering a wound-complication. The only patients 
I have lost were those who could not withstand traumatism, 
and some of these survived only a few hours. 

I could quote Guyon, the member of the Surgical Society 
who has most rigorously applied the Lister dressing, and 
whose first attempts gave the following results : twenty-one 
capital operations, twenty-one recoveries ; seven hernioto- 
mies, five recoveries. 

To show that every one can easily obtain equally good re- 



114 ANTISEPTIC SURGERY. 

suits, I may be allowed to mention the first experience of my 
associate, Dr. Gilbrin, surgeon of the hospital at Metz. In 
1874 he was in utter despair at the results of his surgery in 
the hospital, having exhausted almost all known means to 
prevent the accidents of wounds. He could not operate upon 
a patient without having hospital gangrene set in. Having 
read in the Journal of Practical Medicine and Surgery a 
review of the thesis of Zayas Bazan, he procured it, and 
resolved to devote himself to the strict execution of the pre- 
scriptions of antiseptic surgery. He began on the 1st of 
January, 1875, with this very concise guide. From that day 
on there were no accidents, not another case of hospital 
gangrene occurred ; and yet he performed operations which, 
in the former circumstances, he would not have dared to 
undertake. To-day Gilbrin has perfect results, and is an 
ardent disciple of Lister. 

If we do not yet say, with Socin, of Bale, that every sub- 
ject of amputation who dies of purulent infection or erysip- 
elas is a victim of ignorance, lack of skill, or neglect of the 
surgeon, at least we think this is so near the truth that we 
look upon it simply as a vivacious expression of his idea of 
the power which the Lister method has given to surgery. 



CHAPTER XIII. 

Particular Operations and Dressings. — Practice and Results. 
— Immediate Union. — Plastic Operations. — Extirpation of 
Tumors of the Soft "Parts. 

In describing certain great operations, and the dressings 
adapted to them, I shall point out the particular conditions 
of each case and the results obtainable. 

Immediate union. Plastic operations. 

Many surgeons with good reason say that immediate or 
rapid union is one of the greatest advantages of the method. 
Not only is this assured in all plastic operations, where we 
formerly endeavored to obtain it, but in all operations, what- 
ever may be the nature or the depth of the wound, if its walls 
can be brought into apposition. 

In four years I have seen a failure of union not more than 
two or three times. The wound always unites, if it is anti- 
septically clean and its walls are held in contact with suffi- 
cient firmness. This healing is surprisingly easy, not failing 
on account of the presence of small blood-clots, or the imper- 
fect suture of the parts. 

The deep suture, which some have considered the principal 
feature of the method, is really an accessory measure, and, if 
it is not narrowly watched, it is more likely to hinder than 
to favor healing, by inducing the formation of purulent 
sinuses. 

It is, on the other hand, of the first importance to provide 



116 ANTISEPTIC SURGERY. 

for drainage, and this all the more because parts which have 
been bathed with carbolic acid exude a large amount of 
serous fluid. 

But, these conditions being fulfilled and antiseptic protec- 
tion assured, union will take place not only after all great 
surgical operations, but also after those interferences which 
formerly we hardly dreamed of having it follow, such as the 
opening of large abscesses and articulations. 

I have had union in all regions, even in those where 
attempts at healing are often vain, such as the integuments 
of the skull, after removal of wens and lipomata, and after 
contused wounds ; in the face, after operations for the remo- 
val of sequestra. I have always obtained it after operations 
involving the peritoneum, as in strangulated hernia, after 
evacuating large abscesses, and after opening joints. 

It is clear that, to favor this process, it is wise to retrench 
the tendons and aponeuroses which protude in the depths of 
the wound, and to so arrange the various parts that apposi- 
tion shall be perfect. It is almost a matter of indifference 
what materials are employed to effect coaptation ; metal, car- 
bolized silk, and catgut, all in turn have given good results. 

In plastic operations drainage may be entirely useless, or 
may be accomplished with a bit of protective. It is well to 
cover the united parts with fine linen saturated with boracic 
ointment, and cover it with boracic dressing. If the flaps 
are large, it is an excellent plan to wash them with carbolic 
acid ; if they are small, the boracic solution may be sufficient. 



Removal of tumors from the soft 

All the tumors to which a common treatment is applicable 
may be described together : superficial and deep lipomata, 
tumors of the breast, tumors of the parotid, degenerated 



REMOVAL OF TUMORS. 117 

ganglions, etc. In all these cases I have tried the antiseptic 
method, and I will give the general rules, which should be 
followed. 

The incisions, whether single or multiple, should expose 
the tumors in their entire extent. A long incision is not a 
disadvantage, as the scar is linear, and it gives an opportunity 
for radical extirpation, and prompt and certain arrest of 
hemorrhage. 

All tissues which wilf prevent the healing process, such as 
fibrous envelops and cjst walls, should be carefully removed. 
The cavity produced is washed out with strong carbolized 
water, after bleeding has been stopped. I have often done 
it with an eight per cent, solution of chloride of zinc, with 
very good results ; but a livelier reaction and greater pain 
are liable to follow. 

If the soft parts which are to be united are very far apart, 
one, two, or three deep stitches may be taken, compression of 
the drainage tubes always being scrupulously avoided. On 
the following days a strict watch should be kept on them, 
that they may be removed as soon as they have fulfilled their 
mission. 

There is danger that the superficial stitches may be drawn 
too tightly. Silk or catgut may be used, but I prefer silver, 
though sometimes employing catgut. The last is especially 
applicable to wounds of small extent. This thread, which 
swells by absorption of moisture, must be carefully watched. 

Drainage is very important, and, if the cavity is of great 
size, it is wise to insert several tubes, and remove them as 
soon as their work is done. 

Compressiou with carbolized sponges placed in the dress- 
ing above the protective is here a great assistance. They are 
of advantage by absorbing the discharge and favoring apposi- 
tion by the compression which they exert. 



118 ANTISEPTIC SURGERY. 

I have extirpated a large number of different kinds of 
tumors. I may mention the ablation of a mass of enlarged 
lymphatics from the axilla of a little girl of fifteen. The 
glands extended as high as the clavicle ; and yet, after the 
lips of the wound were sutured, and the dressing carefully 
applied with sponge compression, complete healing of this 
immense cavity took place in two weeks. I have got com- 
plete and rapid healing after the removal of an enormous 
lipoma of the nape, and also after ablation of mammary 
tumors. 

In all cases of tumor, it is of the utmost importance to 
obtain very rapid union, for without it healing is indefinitely 
delayed ; we must not be afraid to bring the lips of the wound 
together even forcibly, if we watch the sutures and are ready 
to loosen them at the least sign of inflammation. In these 
cases, the wound should be dressed daily. 

In the treatment of tumors, the salicylic wadding or lint 
is often useful to make compression upon the remaining 
cavity. 



CHAPTER XIV. 

Compound Fractures. — Purification. — Immobilization. — Gun- 
shot Wounds in Military Surgery. 

The antiseptic treatment of compound fractures and gun- 
shot wounds gives marvellous results ; but these depend 
mostly upon the pains bestowed upon the first dressing. As 
the air has penetrated to a greater or less extent, we should 
not concern ourselves as particularly with the application of 
the spray as with the perfect purification of the wound and 
all its sinuosities. At the time of the subsequent dressings, 
the wound naturally being supposed to be aseptic, the spray 
is of the utmost importance. 

The wound and the surrounding parts having been 
thoroughly washed in the one-to-twenty solution, we care- 
fully examine it and find out whether it will be possible to 
reach with injections to the bottom of its cavities. If these 
are large, with narrow orifices, we need not hesitate to en- 
large the openings sufficiently to insure purification. We 
do this the more readily because, after the washing is com- 
pleted, it is easy enough to take a few stitches and close the 
wound of the bistoury. It is also well to secure the detached 
flaps with sutures. 

The washing of the cavities should be scrupulously made 
with strong carbolized water, and for this purpose a good 
rubber bulb charged with the fluid is very convenient. 

If the wound-cavity is not uncovered, it is very convenient 
to introduce a soft tube, and make the injection through it ; 
in this way the distant crevices can be reached and the return 



120 ANTISEPTIC SURGERY. 

of the fluid assured. This last point is exceedingly im- 
portant, for we must not forget that there are loosened flaps 
and denuded bone, and by forcible injections the injuries of 
the soft parts may be aggravated, and hemorrhage is provoked. 

In cases where the fracture dates far enough back to have 
become poisoned, or where it has been contaminated with 
impurities at the time of injury, it may perhaps be well to 
use a twenty-per-cent. alcoholic solution of carbolic acid for 
the washings and injections. But it should be borne in mind 
that this solution is powerfully caustic. We should be mod- 
erate in the use of it, not slopping it upon the skin, which it 
will burn, and not forcing it violently into the tissues, lest it 
excite active inflammation. 

The aqueous solution gives the blood a chocolate-brown 
color ; the alcoholic imparts a gray hue to the blood and 
uncovered muscles which shrivel at its touch, and the burn- 
ing sensation is intense ; whereas, in the first case, the patient 
has little suffering. 

If the fracture is of several days' standing, and suppura- 
tion has set in, we must not hesitate to freshen the cavity 
with the curette and purify it with chloride of zinc. In this 
case, the greatest circumspection should be observed in the 
injection, and, as the solution is very caustic, its complete 
return should be insured. I do not much favor its employ- 
ment in the beginning for a fresh fracture. It has, indeed, 
been recommended ; but it seems to me to be, at least, use- 
less in such cases. 

In compound fractures the care bestowed upon the drain- 
age should be in proportion to the irregularity of the cavity. 
It should be aided by gentle compression with sponge or 
gauze. At each dressing, one can make sure that there is no 
retention of fluid, by making light pressure and thus empty- 
ing the culs-de-sac and ensuring rapid repair. 



PLASTER BANDAGE USEFUL. 121 

It is useless to insert the drains as far as the centre of the 
fracture. It suffices to place them below and along side of 
the bones. 

We should bear in mind that it is generally of no use to 
repeat the injections, the dressing having been once well 
applied, and that, on the contrary, this proceeding disturbs 
repair, prolongs the cure, and even provokes suppuration. 

Ordinarily the dressing is made with quite thick layers of 
gauze, because its form is necessarily irregular, and because 
there is often abundant discharge. 

Of all solid appliances the plaster bandage is the most 
easily combined with the antiseptic dressing. If the open- 
ings in the apparatus are not very large, it is well to line 
their edges with antiseptic gauze, under which we slip the 
impermeable. The dressing must be frequently renewed. 

Finally, in the dressing of compound fractures, the sali- 
cylic wadding or jute answers a good purpose in filling up 
empty places and completing the dressing. 

In the cases where I have feared that antisepsis was not 
well assured, on account of the necessary narrowness of the 
openings of the apparatus, I have enveloped the limb and 
the wounded region above the dressing with a kind of ban- 
dage of Scultetus, formed of large bands of carbolized gauze. 
Another piece of impermeable placed above assured me that 
the fluids which ran from the dressing, being received by the 
carbolized bands, could not putrefy. In the first days of 
treatment one cannot take too many precautions, when the 
discharge of fluids is abundant. 

The dressing is evidently as favorable to the repair of bone 
as to that of the soft parts, and one is surprised to see that 
the necessity for immobilization is only relative. Obviously 
the bony fragments should not be disturbed by large move- 
ments. But while authors attach great importance to the 

9 



122 ANTISEPTIC SURGERY. 

immobilization of a compound fracture, we find here that 
with small movements and an apparatus moderately immo- 
bilizing, consolidation goes on well, and no inflammatory 
complications result. This fact is of essential value in the 
treatment of certain fractures. I have even acquired the 
habit, in cases of fractures into or near joints, of not immo- 
bilizing completely, in order that I may try to preserve the 
articular movements. 

In 1877, at the Hospital of Lariboisi£re, I treated in this 
manner a man who had a fracture just above the right elbow, 
with considerable crushing of the integuments, from being 
run over by a carriage. It was put up in a gutter-like splint, 
and, every time it was dressed, movements were made in the 
joint. The healing was very rapid, the callus was perfectly 
solid, and he had sufficiently extended movements of the 
elbow when he was discharged. I attach importance to this 
fact, because I am one of those who believe in the influence 
of the immobilization upon rigidity of joints. 

The progress of compound fractures is remarkable. At 
first, there is an abundant discharge of blackish serum ; in 
the following days the serum becomes turbid -, sometimes it 
approaches the appearance of pus, without becoming creamy; 
then, as cicatrization goes on, there is no longer any discharge 
from the wound excepting a slightly viscid serum, strongly 
resembling synovia ; finally the discharge dries up and the 
wound is closed. If the bone is extensively shattered, this 
discharge lasts some time ; it is seen in bad fractures of the 
leg. But if the break is not extensive, reunion is rapid and 
is accomplished absolutely by first intention. 

This very happy progress of fractures is observed in shafts 
of large bones, in small bones, and fractures into joints with 
the same regularity. In 1877, I could show at one time in 
the service that I directed at the Hospital of Lariboisi&re, a 



ANTISEPSIS IN WAR. 123 

fracture of the lower end of the humerus, opening into the 
joint, multiple fractures of metacarpal bones and phalanges 
in a crushed hand, a fracture of both malleoli communicating 
with the articulation, and a fracture of the femur extending 
into the knee-joint. All these patients simultaneously re- 
covered without suppuration and with the preservation of 
the movements of the injured joints. The cases in which 
suppuration continues "are exceptional, and, in the greater 
number, our failure is to be attributed to the impossibility of 
sufficiently purifying the cavity. 

The most formidable compound fractures are seen in mili- 
tary practice, and our chief concern is to keep infection from 
the wounds before they can be treated in a thoroughly anti- 
septic manner. Nussbaum, who says that " the fate of a 
wounded man depends almost entirely upon, the physician 
who treats the wound during the first hours," is of opinion, 
like the greater part of German surgeons, that the best thing 
to do is to furnish the soldier with a tampon of salicylic 
wadding or jute, tied up in a piece of salicylic gauze. The 
tampon being immediately applied to the wound protects it, 
and the salicylic acid, dissolving in the discharged fluids, 
prevents infection. The first immobilizing dressing of the 
limb ought to be made without examining the wound, since 
the patient, in the ambulance or hospital, can have the bene- 
fit of a perfectly antiseptic method, which is impossible upon 
the battle-field ; and a wound which has not been opened in 
any way will not receive any additional poison. 



CHAPTER XV. 

Osteotomy. — Rachitic Curvatures and Genu Valgum. — Frac- 
tures of Joints. — Resection in False Joints. 

An operation which consists in deliberately making a com- 
pound fracture, and that, too, generally merely for the correc- 
tion of a deformity, was incapable of full development until 
one could be assured that this wound, if sufficiently protected, 
would expose the patient to no greater danger than would a 
wound of the soft parts in like circumstances. Nowadays we 
do these operations fearlessly, even if they open more or less 
extensively into joints. In the beginning of his antiseptic 
practice, Lister set the example, since often followed, in the 
case of a man who had outward luxation of the foot. He cut 
down upon the vicious callus, laid the articulation freely open, 
straightened the foot, and obtained perfect healing without 
suppuration. 

Some years after he made an operation of the same kind 
for a vicious callus of the elbow which prevented extension 
of the limb. He opened the joint, excised the exuberant ma- 
terial, and the patient recovered without any drawback, and 
regained all the movements of the member. 

Resection of a vicious callus may be easily made, and a few 
days are sufficient to insure healing. Dr. Perier recently 
showed the Surgical Society a young man on whom he had 
operated for a bad callus of the clavicle, which threatened to 
perforate the skin. He excised all the prominent portion, 
and in a few days the healing process was completed, union 
having been obtained by first intention. 



CORRECTION OF BONY CURVATURES. 125 

Section, with or without excision of a wedge-shaped 
fragment of bone, has been practised for the purpose of 
straightening rachitic curvatures of the lower limbs, to correct 
genu valgum, and to relieve ankylosis of a neighboring artic- 
ulation. 

In genu valgum, the operation is done by making a sec- 
tion of the articular surfaces in order to displace a condyle, 
or by removing a portion of bone to straighten the limb, the 
joint being opened or'liot, as the case may be. Although 
these operations were made prior to the introduction of the 
antiseptic method, they were not really justifiable. 

The directions, which a surgeon who does these operations 
antiseptically should observe, are as follows : — 

Instead of striving, as formerly, to make the incisions as 
small as possible, so that the operation may be more or less 
subcutaneous, we make large openings, which allow us to 
freely uncover the bone, and make the section of it in the 
best possible conditions. 

Formerly, the saw was regarded as much more dangerous 
than other instruments, but we do not now consider it an 
important factor in the production of septic complications. 
However, to insure perfect results, it is indispensable that 
all particles of bone should be washed out of the wound. 

Finally, we must make sure that the drains do not inter- 
pose between the osseous surfaces which ought to be in con- 
tact, for this little accident easily happens and is a source of 
great irritation. 

Besides these directions, there is nothing special to add. 
Extension, traction, movements, or fixation will be employed 
in all these operations, as if the antiseptic method were not 
used. 

In making operations of this kind, it is well to remember 
a case reported by Lister in the British Medical Journal, 



126 ANTISEPTIC SURGERY. 

in 1877. It was a recent fracture of the patella, with con- 
siderable separation of the fragments, and the operation con- 
sisted in opening the joint, emptying it, carefully cleansing 
the pieces, suturing them together with silver wire, and drain- 
ing the articulation with a bundle of horsehair. In three 
weeks cicatrization was complete, but he waited until consoli- 
dation was perfect before he withdrew the wire. He has 
repeated this operation successfully on old fractures. 



Resection for the relief of false joint, also, has become an 
operation free from gravity, and, with the addition of the 
antiseptic protection, may be successfully performed in the 
same manner as formerly. I saw a beautiful example of this 
— a pseudarthrosis of the femur — in the service of .Lister, in 
1875. But we must not lose sight of the fact that the anti- 
septic method reduces to their minimum the phenomena of 
irritation in a wound. Now, it happens that, while the 
osseous extremities need to be excited in order to form the 
callus, the reaction is insufficient, and the wounds heal rapidly 
without our obtaining the desired result. 

Three years ago I operated upon a man for false joint in 
the right humerus. In spite of very extensive resection of 
the fragments, in spite of the pulling and bruising of the soft 
parts during the operation, at the end of eighteen days cicatri- 
zation was perfect, without the patient's having had a touch 
of fever. But the mobility was not relieved ; in spite of 
sufficient juxtaposition of the parts, no callus was formed. 

Other surgeons have had the same experience, and, follow- 
ing Volkmann, we have established the following principle. 
During the first days we dress antiseptically, until danger of 
the more serious complications is past. Then, while there 



RELIEF OF FALSE JOINT. 127 

remains only a moderate passage between the ends of the 
pieces, we abandon the antiseptic method, and let the infected 
air enter the cavity sufficiently to excite osseous secretion. 

Most operators, however, insist upon the necessity of fast- 
ening the fragments, either by metallic suture, a peg of ivory, 
iron nails plated with tin, as recommended by Nussbaum, or 
a silver screw, as Langenbeck advises. When the fragments 
are united with these large and irritant bodies, a sufficient 
formation of callus is pfovoked by their presence, and we can 
dispense with the introduction of septic air, which is always 
a disturbing procedure. 



CHAPTER XVI. 

Amputations and Disarticulations. 

The greater part of the dressings which are at all comparable 
to the. Listerian were only intended for amputations at first, 
as, for example, the Bordeaux and the wadded dressings. As 
we have already seen, the Lister method in amputations is 
only a particular application conforming to general rules. 
These rules have produced so profound a modification in the 
phenomena of repair that they have largely changed the con- 
ditions of amputations. Not only do the subjects of amputa- 
tions recover, but the ease of recovery is such that the surgeon 
is much more at liberty to select the operative procedure in 
the best interests of prosthesis, and to employ methods to 
which, until now, there were objections. 

Thus, flap methods are reckoned first, and the procedures 
of Marcellin Duval, which have been applied mathematically 
at all points of the limbs for the formation of large flaps, are 
in the foremost rank. 

This is susceptible of easy proof, as I can show with respect 
to amputation above the malleoli with a large posterior flap, 
in a private patient at the present moment. Several times I 
have done Guyon's operation, which, while it differs in its 
details from that of Duval, is based upon an analogous prin- 
ciple to that which constitutes the general method of the 
eminent naval professor ; and I am competent to judge after 
what I have observed of the behavior of the large posterior 
flap. 



ANTISEPTIC AMPUTATIONS. 129 

I was able to show the Surgical Society the very remarka- 
ble results which I obtained in a wounded man, who recov- 
ered in twenty days. There was linear union of the flap, the 
parts were perfectly flexible, there was entire absence of 
inflammation about the bone, and the patient walked about 
upon the flap with the aid of a very simple apparatus of 
Werber's. 

In this amputation I have recommended and practised 
excision of the nerve^ trunks, as has already been advised in 
amputations. Here, where the patient has to walk upon a 
flap in which there is a large nerve, I consider this step much 
more necessary, and twice I have excised the posterior tibial 
as high as possible. The results have been excellent, and I 
am pleased to see that Guyon has adopted this step in his 
operation. Soon after, I operated upon a man in disadvan- 
tageous circumstances, and I observed the same regularity 
of scar and perfect flexibility of flaps at the expiration of 
twenty-four clays. Guyon has made the same observations 
in his cases. 

So, taking these cases of perfect, permanent union of large 
flaps as examples, I say that there is no longer any objection 
to making them as Duval proposed ; and I am of opinion, also, 
that excision of the nerve trunks augments the serviceable- 
ness of the stump and diminishes suffering during treatment. 

What, then, are the rules to follow in applying the anti- 
septic method to amputations ? Choose those methods of 
operating which make the application of sutures easy ; en- 
deavor to prevent everything which can interfere with union ; 
retrench tendons and aponeuroses, and superfluous muscular 
tissue in the flaps ; make a high section of the bones ; x take 

1 The over-heating of the bone, which is believed to stand in a causa- 
tive relation to the necrosis of the surfaces which occasionally occurs, 
may be largely avoided by pouring weak carbolic solution over the saw 
during the section. 



130 ANTISEPTIC SURGERY. 

pains with the suture, and, above all, drain by one, two, or 
even three tracks. 

The deep suture is not at all a necessity of the dressing, 
indeed is only occasionally called for, as when flabby flaps 
need to be held together, when the flaps are insufficient, as 
happens sometimes in amputations after traumatism, etc. I 
think I have never used it more than twice in large amputa- 
tions. I may add that I have seen a pseudo-Lister dressing 
in which union was completely prevented by the fault of 
these deep sutures. 

Drainage may be well insured generally by two drains at 
the base of the flap ; but if it is large, a third may be neces- 
sary. The drains may go close to the bone, but should not 
irritate it ; and it is well to shorten them as soon as possible 
in order to avoid the danger of their remaining in contact 
with it. The opposite practice was formerly followed by 
those who used drains in stumps. 

Gentle compression is often very favorable to union. I do 
not agree with Volkmann in thinking it desirable to make it 
very firm, and I usually employ in amputations layers of 
pressed sponge which have been soaked in the strong solution 
of carbolic acid. 

Close watching of the sutures and drainage is more essen- 
tial here than in other wounds. We must not remove the 
clots, or worry the flaps, or make injections under them ; but 
we should favor drainage of fluids, and cut the stitches as 
soon as they begin to irritate the skin or provoke the forma- 
tion of a little pus. 

Disarticulation wounds ought to be treated exactly like 
those of amputation in the continuity of limbs. The thro wing- 
off of the articular cartilages by suppuration is not a necessity, 
as we find that these wounds close like the others. They 
are not more dangerous than other amputation wounds, but 



DISAKTICULATIONS. 131 

they should be drained with particular care. In all great 
amputations there is need of providing good drainage ; and 
many surgeons, only half doing this, have failures which are 
a decided contrast to their success in operations upon less 
extensive surfaces. 

Great pains should be taken with the spray, which ought 
to envelop all the parts involved. And in the subsequent 
dressings, too, I advise especial attention to this point. 

All the statistics of -experts in this practice contain reports 
of large disarticulations, even that of the thigh, which have 
healed just like the smaller amputations. One of the most 
interesting of my cases occurred in the person of a little girl 
of six, in the Saint Eugenie Hospital, on whom I performed 
disarticulation at the left shoulder. She had been run over 
by a street-car, and the injury was so extensive that I was 
obliged to make my amputation right through the mangled 
tissues. I employed the procedure of Larrey, carefully ex- 
cised the nerves, and put in six metallic sutures. At the 
second dressing, which was made on the fourth day, union 
seemed to be complete. The stitches and drain were removed 
on the sixth day. At no time did the dressings cause any 
pain. 

In the treatment of amputations, it is particularly important 
to persist in the dressings until cicatrization is perfect. For 
lack of this precaution, one often meets with tedious compli- 
cations, such as osteo-periostitis, pain in the stumps, and 
flstules. I have previously mentioned this fact in speaking 
of the duration of the dressings, but it cannot be repeated too 
much, for that is not a moderate advantage of the method 
which protects those who suffer amputation from all the acci- 
dents which are likely to embitter their existence. 



CHAPTER XVII. 

Wounds of Joints. — Removal of Foreign Bodies. — Operations 
for Fractures and Dislocations. — Opening of Joints for 
Hydrarthrosis. — Opening of Diseased Joints. — Opening of 
White Swellings. — Antiseptic Irrigation of Inflamed Ar- 
ticulations. 

In all surgery there are no cases which more thoroughly 
demonstrate the value of the antiseptic method than those 
involving the opening of joints. Doubtless it sometimes 
happens that articular wounds heal without complication 
in favorable media ; but when the circumstances are bad, it 
is only exceptionally that we have happy results. It is also 
true that, in a very recent period, the great care bestowed 
upon surgery has had the effect of diminishing the accidents 
of articular injuries ; but up to the present time there has 
been no surgeon who could, without anxiety, contemplate the 
opening of a large joint, whether the result of accident or 
made by the surgeon himself. 

Three principal accidents are feared as the consequences of 
such wounds. 

First, traumatic arthritis, so likely to be followed by rapid 
and formidable accidents, general involvement of the system, 
purulent infection, and speedy death. 

Second, interminable suppurations, within and around the 
joints, terminating in indefinitely delayed recovery, or death 
at a distant date. 

Third, loss of the functions of the joint, if healing does 
take place, even in the favorable cases. 



INJURIES OF JOINTS. 133 

Just imagine that, after the employment of the antiseptic 
method, the wounds do not inflame, do not suppurate, and 
that purulent infection is unknown, and you will understand 
how it is that the healing of articular wounds has become 
the regular thing, and that the opening of joints by the 
surgeon deserves to rank among the operations which are 
safe, and as regards death, harmless. 

Articular wounds. 

Wounds of joints form a very bad class, especially if they 
have continued a considerable time without proper treatment, 
because we cannpt then be sure of expelling the germs from 
all the recesses. This is a point of vital importance. The 
sinuosities of the wounds should be very carefully washed 
out with a powerful antiseptic, the strong carbolic acid water 
ordinarily answering this purpose. In certain cases a stronger 
liquid may be indicated, and then we may use a twenty-per- 
cent, solution of carbolic acid in alcohol. In these, as in all 
tortuous wounds, the injected liquid must all be evacuated, 
or else there may be excited too intense irritation and the 
carbolic-acid poisoning which has sometimes been observed. 
Where the wounds are so sinuous that it is difficult to purify 
them, we should not hesitate to lay them freely open. Great 
attention should be bestowed upon the stitches, which ought 
not to be too tight. 

Drainage must be abundantly provided, and it is better to 
use several tubes than only one. If the wounds are very 
simple and straight, they will rapidly heal, and drainage is of 
brief duration. I advise never closing them completely at 
first. When they are not simple and straight, it is wise, after 
withdrawing the drain, to close them only when the serous 
secretion is very moderate in amount. 



134 ANTISEPTIC SURGERY. 

I need not dwell upon the practice and give examples of 
this treatment, because it differs so slightly from that which 
I have recommended in case of compound fractures, espe- 
cially those which involve the joints. 

Operations. 

The operations which are performed upon healthy articu- 
lations, or those which are nearly so, are particularly in- 
teresting. I shall make no reference to the cases in which 
the articulations are opened in the course of an operation in 
the vicinity, and those in which an exploratory incision is 
made, as proposed by Annandale. 

Removal of foreign bodies. 

The facts concerning the direct extraction of foreign bodies 
from joints, laid open for this purpose, are certainly very 
curious. 

We know how good reason there formerly was for consid- 
ering this an operation of a serious character. B. Bell, in- 
deed, thought it even more dangerous than amputation of the 
thigh at the upper third. Now, following the example set 
by Lister ten years ago in Glasgow, in case of a large foreign 
body in a joint, Barwell, in London, has made a very careful 
study of the value of the antiseptic dressing. But Saxtorph, 
of Copenhagen, by a considerable number of operations, has 
shown its possible success better than anybody else. He has 
reported twelve cases with only one death, and in this case, 
too cruelly illustrative, the patient tore off the dressing and 
was attacked with purulent infection. 

Following in these footsteps, I removed at the Hospital of 
Lariboisiere, on the twenty-eighth of October, 1876, a large 



EXTRACTION OF FOREIGN BODIES. 135 

foreign body, performing a very unusual operation, that of 
extracting a body from the back part of the joint. An incision 
on the outside of the popliteal space permitted me to reach 
the body, which was deeply situated. The patient, a man of 
fifty-one years, had only four dressings; the wound was 
healed in nine days, and he could support himself upon the 
limb in three weeks. The mobility of the articulation was 
not in the least impaired. 

The points to be observed in this special case are as fol- 
lows : make a free opening ; take as many stitches as are 
necessary to effect apposition, and take them deeply, as the 
tissues in this region are generally thick from close intersec- 
tion. The drainage must be carefully made, and it should 
not last long. In my opinion, it was because he neglected 
drainage in the first place that Eugene Bceckel lost the patient 
whose history he gave in the Strasbourg Medical Gazette, in 
October, 1877. His first operation was successful, but in the 
second case the patient succumbed to purulent infection. 

I consider it not only useless, but even injurious, to rigor- 
ously immobilize the limb after the operation. I put it all 
dressed into a trough, and remove it at each dressing. There 
is little need of renewing the dressing, except upon the first 
day. The operation in itself is simple. The wound is to be 
washed in carbolic-acid water, which, however, should not be 
injected into the joint. Not to uselessly irritate the articula- 
tion and not to immobilize it are two important factors in the 
prevention of all tendency to ankylosis. 

Without any question, this is the operation to choose in 
the cases where there are foreign bodies in joints. The op- 
eration of Goyrand is difficult and murderous, although less 
serious than the old method of freely laying open, as has been 
demonstrated by Verneuil. 



136 ANTISEPTIC SURGERY. 



Operations for fractures and dislocations. 

There are certain operations upon joints which are nearly 
sound which, at the first glance, are appalling. Thus, Lister 
has often opened joints, on account of recent or old fractures 
which have involved them, to straighten limbs, as after luxa- 
tion of the foot ; to excise pieces of vicious callus, as, for 
example, in the elbow and tibio-tarsal joints ; and, finally, to 
bring together by suturing the two widely separated frag- 
ments of a recently broken patella. 

Moreover, we must reckon under the head of articular 
wounds the operations made for the cure of irreducible 
luxations. Volkmann did this for an iliofemoral dislocation 
of two months' standing. Not having succeeded in reducing 
the luxation, he excised the head of the femur, and his pa- 
tient was healed by immediate union. 

Operation for hydrarthrosis. 

An operation which seems even much more rash is often 
practised by Professor Lister upon obstinate hydrarthroses. 
At first it was a singular surprise both to me and my fellow 
assistant, N. Gueneau de Mussy, in one of Lister's demon- 
strations, in 1875. It consisted of freely opening the knee 
joint in a case of persistent hydrarthrosis, of carefully empty- 
ing it, even inserting the fingers to accomplish this, and 
draining by the method described. Thus the radical cure of a 
hydrarthrosis of the knee was accomplished without ankylosis. 
Through Dr. Rice, then interne at the hospital, I had news 
of the patient referred to above. He was completely cured at 
the end of two months, and walked with ease. I have seen 
other similar cases, and Panas successfully performed this 
operation at Lariboisiere. 



DISEASE OF JOINTS. 137 

The opening should be large in order to give free vent to 
the fluid. The outer side, being more dependent, is to be 
preferred for the incision. The sutures should be taken with 
precision, and should, if possible, include all the tissues, even 
the serous, and are consequently somewhat difficult to insert. 
At least one tube is required for drainage, and often two will 
be needed. The patient, as above, should be dressed without 
complete immobilization, and the joint moved even before the 
wound is healed. 



The opening of diseased articulations ; suppuration. 

The opening of diseased articulations gives results which 
one would be far from anticipating. When there is pus in a 
joint, a free opening permits the evacuation of all the morbid 
products ; sutures are made, and the wound closes, healing in 
from fifteen to thirty days. Here a large, bold opening should 
be made at the outer side of the patella, if possible ; this per- 
mits the escape of the pus and the detachment of the false 
membranes ; the fingers are passed under the patella to ex- 
plore and to cleanse the parts ; and carbolized sponges may be 
introduced into the joint and wiped against the suppurating 
walls without fear of doing harm. 

Strong carbolic water should be freely used in washing out 
the joint. There will generally be considerable bleeding 
during these proceedings, but it need give no anxiety. The 
return of the fluids which have been introduced should be 
most strictly accomplished. After this the wound is sewed 
up and drained almost exactly as in a case of chronic dropsy 
of the joint. 

I have made this operation five times with remarkable re- 
sults. At the Lariboisiere, in January, 1877, 1 opened a knee 
for purulent arthritis in a man of thirty-three, who was suf- 

10 



138 ANTISEPTIC SURGERY. 

fering from a sort of purulent infection. In this case, which 
I have seen very often since, the results of the operation 
were very simple. In twenty days the knee was completely 
cicatrized, and in three months flexion of the leg was accom- 
plished with entire ease. 

At the same hospital and in the same year, I opened the 
knee of a man whose only alternative was amputation of the 
thigh. He had osteoperiostitis of the femur, attended with 
the detachment of a great deal of bone. A large sequestrum 
and a number of completely infected abscesses prevented my 
maintaining the asepticity of this wound until the very end 
of treatment ; but, for all that, after some months the patient 
walked out with a good use of his limb. In this case, recog- 
nizing the previous infection, I injected into the cavity, at 
several different times, a twenty-per-cent. solution of carbolic 
acid in alcohol. 

Since then I have opened a knee at the Maternity for a 
most serious arthritis in a puerperal woman. The patient 
was nineteen years old and entered for her lying-in on the 
ninth of July, 1878. She had eclampsia, and was delivered 
with the forceps. After a little an eruption broke out, and 
several joints were seized with pain. The left knee became 
tumefied and extremely painful, chills occurred on the tenth 
of August, and again on the twentieth, the last being very 
violent. The limb reached an enormous size, the suffering 
was atrocious, and rest was impossible. The puerperal state 
and the extreme gravity of the local lesion constituted a 
frightful combination, and the general condition was miser- 
able. On the twenty-seventh of August, an opening four- 
teen centimeters long was made on the outer side of the 
joint. The pus was abundant, the false membranes thick, 
and a large quantity of blood escaped into the articulation. 
The suffering instantly disappeared. At the end of twenty- 



FREE OPENING OF THE JOINTS. 139 

seven days the joint was closed, and the patient got up at the 
end of two months. Little b} T little walking became easier, 
but a good deal of stiffness remained in the joint five months 
after, the patient refusing to allow passive motion to be made. 
She walked very well without fatigue, gained rapidly, recov- 
ered all her movements, and found herself so well that she 
was unwilling to submit to even a little operation to increase 
mobility. 

More recently, being called in consultation by M. S6e at 
his private hospital, I opened the right knee of a young 
Creole who had purulent arthritis, the sequel of a deep angei- 
oleucitis of the leg. In spite of the general and local unfa- 
vorable conditions, we obtained the best result, the knee being 
closed in fourteen days, with no deep inflammation of the leg, 
and movement of the articulation already being established. 

M. B., aged twenty-two, had in the right calf an enormous 
abscess consecutive upon angeioleucitis of the foot, and M. 
See opened it on the fifteenth of November, 1878. On the 
twentieth of December, the patient began to have pain in the 
knee, the wound in the calf continuing to suppurate. The 
rapid swelling of the articulation and the repeated chills left 
no doubt as to the presence of pus, and on the twenty- 
seventh of December a needle was inserted and a moderate 
quantity of pus evacuated. Three days after, the knee had 
attained a great size, and the general state was bad. An 
opening ten or twelve centimeters long was made on the 
outer side of the joint, and was followed by the escape of pus 
and false membranes. I passed my fingers into the articula- 
tion, washed it out with strong carbolic solution, and sewed 
Up the wound, excepting the upper angle, in which I placed 
two drains side by side. The discharge for the first two days 
was abundant, but afterwards there was merely an exudation 
of serum. The drains were removed on the ninth of January, 



140 ANTISEPTIC SURGERY. 

1879, the sutures on the tenth, and on the twelfth cicatri- 
zation was complete. The development of a new abscess in 
the calf interfered with the healing, and the pain which it 
produced prevented the patient's permitting sufficient flexion 
of the knee. However, in April he began to bend it well. 

At the Salpetriere, in the service of my colleague, M. Ter- 
rier, I operated upon a woman of thirty-seven years, the 
beginning of whose arthritis dated back to the puerperal con- 
dition, after a miscarriage in the first part of December, 1878. 
She had had abscess in the calf, and in December, June, and 
January she developed purulent arthritis in the left knee. 
From the fifteenth of January to the twenty-third of May 
she was under the care of Professor Gosselin, who punctured 
the knee and drew out some pus. On the twentieth of April 
she entered the Salpetriere in the service of M. Terrier. The 
left lower limb was in a very serious condition, the tumefac- 
tion being enormous, the pain unendurable, the fever high. 
The limb was actually deformed, the fluctuating accumulation 
rising up eighteen centimeters above the patella. On the 
twenty-third of April, I made an incision eight centimeters 
long on the outer side, and more than a liter of pus and false 
membranes gushed out. I washed out the cavity without 
passing my fingers under the knee-pan. The bleeding was 
profuse. I made another incision on the inner side, parallel 
to the first. Then I sewed them up, leaving only enough 
room for a drain on each side. The tracks of the tubes did 
not cicatrize until the thirteenth of June. When the patient 
was discharged, on the twenty-sixth of July, she walked well 
and was able to flex her leg to a right angle. 

I dwell upon these examples in order to give the reader a 
proper comprehension of his resources. It may be claimed 
that by no other proceeding could such results have been ob- 
tained ; and yet they might have been more rapid, for almost 



INFLAMED ARTICULATIONS. 141 

all the operations were made in circumstances which were 
only moderately favorable, and in services where the attend- 
ants were not accustomed to this mode of dressing. 

After having given a fair trial to the trough, I have come 
to the conclusion that it is almost useless, and that immobili- 
zation may be dispensed with — a great advantage in most 
cases, since it enab.les us to establish motion in the articula- 
tions almost immediately. In the numerous cases of articular 
suppuration and of epiphyseal osteo-periostitis, I think we 
may practise it with profit, freely opening the abscess and 
boldly trephining the diseased bones. 

The opening of white swellings. 

An operation which seems to give excellent results is that 
of making large incisions into joints which are attacked with 
white swellings. Sometimes, as Lister says, this suffices to 
start the patient on the road to recovery. I have practised 
it with success. If, after some time, there is no amelioration 
of the patient's condition, resection should be resorted to. 

Unfortunately I have not been able to keep track of the 
patients upon whom I have practised such incisions. I in- 
cised the elbow of a young woman, a private patient, and she 
got along admirably during the two months I was able to 
keep watch of her. Saxtorph has reported cases of this kind. 
Concerning the operation itself there is nothing in particular 
to say, as it does not materially differ from that for articular 
abscess. The dressing should not be abandoned until cica- 
trization is absolute. 

The antiseptic irrigation of inflamed joints. 

Schede has recommended an operation which can be prac- 
tised freely upon inflamed joints. It consists in puncturing 



142 ANTISEPTIC SURGERY. 

the articulations which are attacked with rheumatic inflam- 
mation and distended with excessive secretion, then empty- 
ing them, injecting weak carbolic solution, and repeating this 
injection until the fluid returns clear. The canula is then 
withdrawn and the limb is immobilized. This little opera- 
tion, being made with all the antiseptic precautions, is with- 
out danger, and is followed by relief and rapid recovery. It 
is now so extensively practised in Germany that it is even 
done in cases of acute rheumatism, when there is much swell- 
ing of the joints. 

The manner of operating is as follows : all the antiseptic 
precautions being observed, the puncture is made with a 
medium-sized trocar; a two-and-a-half per cent, solution of 
carbolic acid is then thrown into the joint ; after this escapes, 
another injection is made, and this process is repeated until 
the discharged liquid is clear. 

After the operation the reaction is variable. Some patients 
have none ; others have some swelling, at first painful, after- 
wards a little persistent. 

The results of this practice are excellent. Carl Rossander, 
of Stockholm, who has followed Schede, praises it highly. 
He has even employed it in the case of a child a year and a 
half old. 



CHAPTER XVIII. 

Resection of Joints. 

For a long time French surgery hesitated before this class of 
operations: for, while resections of the elbow, shoulder, and 
ankle were often practised, those of the knee and hip were 
very rare, and those of the wrist were almost entirety avoided. 
The legitimate reluctance of conservative surgery ought to 
give way before the antiseptic method. 

Resections may be rejected on account of the immediate 
accidents or the protracted suppurations which follow them; 
persisting fistules and loss of the functions of limbs are the 
direct consequences. Most of the dangers are immediate, 
and secondary accidents are very rare; and, therefore, we 
should be very favorably disposed to these operations. 

Generally they present nothing in particular which requires 
any modification of the dressing. Nevertheless, it should be 
remembered that we have to treat inflamed joints which have 
not and those which have exterior openings. Quite natu- 
rally, in the latter cases it is much more difficult to obtain 
asepsis ; but yet we can secure it very frequently by scraping 
the suppurating surfaces with a curette. In these cases, 
and even in those which have not had an external opening, 
it is always necessary to carefully remove all morbid prod- 
ucts. This is the one step in the procedure upon which suc- 
cess depends. The fungosities must be completely destroyed ; 
for, if they are left in place, they multiply rapidly, impede 
reunion, and provoke suppuration. The surgeon cannot be 
too scrupulous in cutting them away even to the last traces. 



144 ANTISEPTIC SURGERY. 

In the case of certain articulations, as the knee, for example, 
Volkmann goes much further, and advises the careful re- 
moval of the fibrous tissues, which often hinder reunion. The 
drainage is difficult, and it should be made with the utmost 
fastidiousness. 

For resection of the hip and shoulder there are no special 
indications. I have seen Lister effect drainage with horse- 
hair with good results. Extension may be practised from the 
beginning of the treatment. 

In the knee we have the advantage of obtaining solid 
union, and particular pains should be taken to avoid non- 
union, which makes a genuine pseudarthrosis, arising from the 
lack of inflammatory reaction. I pointed this out in speak- 
ing of the treatment of false joints. 

In a communication to the Congress of German Surgeons, 
Volkmann recommended suturing the osseous surfaces. He 
considers the catgut the best material for this purpose, and 
leaves it permanently in the wound. Silver and iron wire 
have also been used with good results. 

At the same time, Volkmann advised the avoidance of the 
use of the saw in articular resections. The bones of people 
who require excision can be cut well enough with the knife, 
and the surface obtained in this way is much better adapted 
for reunion, as the action of the saw leaves an osseous sur- 
face of which a thin layer may mortify. 

Excision of the wrist was strongly advised by Professor 
Lister long before the antiseptic method was proposed ; and 
so it was all ready to profit by the resources of the new sys- 
tem. I have watched his patients in all stages of treatment, 
from the moment of operation until the cure was complete. 
Here the object of the surgeon is to preserve both the form 
of the hand and the greatest possible amount of movement ; 
and, therefore, the professor recommends the employment 



EXCISION OF WRIST. 145 

from the first of a kind of splint of cork with a marked con- 
vexity, upon which the palm of the hand rests. Then, after 
a few days, say at the end of the first week, he makes the 
patient perform the various movements of the fingers at each 
dressing, and this, he says, is the true means of getting good 
results from the operation. Thanks to the asepticity of the 
wounds, this practice of movement, at a very early date, may 
be employed whenever we desire to have a movable joint 
after resection. 

The most salient circumstance in the progress of wounds 
of this sort is the extraordinary rapidity of repair, in illustra- 
tion of which I may mention a knee healed in fifteen days 
under the care of Professor Lister. Auguste Reverdin re- 
cently reported to me that he had actually observed in these 
cases union by first intention. He had seen a child in Volk- 
mann's service, whose wounds were cicatrized in five days 
after resection of the hip. 



CHAPTER XIX. 

Peritoneal Operations. — Strangulated Hernia. — Radical 
Cure of Hernia. — Laparotomy. — Ovariotomy. — Cesarean 
Section. — Porro's Operation. — Cysts of the Liver. 

All operations which involve the peritoneum have a common 
character, whatever differences they may present ; and I in- 
troduce them in the same chapter, because the antiseptic 
method is similarly advantageous in all of them. If the 
method is rigorously practised, the opening of this great se- 
rous cavity is deprived of its proverbial seriousness. Steam 
spray-producers are particularly necessary in these cases, and 
those apparatuses which chill or wet these great uncovered 
surfaces too much are objectionable. 

Kelotomy ; operations for strangulated hernia. 

In the front rank of operations which every- practitioner is 
called upon to make we must place that performed for strangu- 
lated hernia. I have done it a great many times with the anti- 
septic method, and the results have been excellent, though 
sometimes almost unhoped for. As there is no local inflam- 
matory reaction, the chances of peritonitis are insignificant, 
the repair of the injured parts is accomplished more rapidly 
and regularly, and the reduction of the rupture is allowable 
even when the appearance of the intestine is very unprom- 
ising. 

I had been previously pretty fortunate in my hernia oper- 
ations, in which, however, I always employed antiseptic 
washings and closure of the wound ; but I never happened 



STRANGULATED HERNIA. 147 

to have six cures one after another, as occurred in the year 
1877, under the antiseptic treatment ; and of these six some 
were miserable cases, both as regards the age of the patients 
and the duration of the strangulation. Since I began to use 
the Lister method, I have lost only those cases in which there 
was so serious an injury to the knuckle of intestine that per- 
foration rapidly took place. ]My operations have been only 
on persons brought tardily to the hospital by day or night, 
generally after havings been subjected to violent and pro- 
longed taxis, and it is on this account that six consecutive 
cures are so remarkable. 

The irritant action of the carbolic acid upon the perito- 
neum has been dreaded ; and yet it is marvellous to see that 
a solution, so strong as to destroy the epidermis on the 
operator's hands, is borne by the peritoneum without in- 
convenience. 

In the operation for strangulated hernia, in addition to 
the ordinary precautions, I recommend a large opening, so as 
to completely uncover the sac. As soon as the sac is opened, 
its cavity should be washed out several times with the strong 
solution in order to neutralize the products of inflammation 
or hemorrhage of the sac and get them out of the way. Then 
we proceed to the removal of the constriction, which being- 
done, the loop of intestine is carefully washed with the weak 
carbolic solution, before being returned to the abdomen. 
With it some of the carbolized water always enters the ab- 
dominal cavity, but it is of no consequence. Before the 
suture is made, I advise the excision of the greater part of 
the sac, as this proceeding greatly facilitates union, and is of 
advantage with reference to a radical cure. Great care 
should be devoted to the stitches. For a long time I have 
been in the habit of taking a deep stitch at the level of the 
ring. This practice favors radical cure, but it requires a 



148 ANTISEPTIC SURGERY. 

great deal of watchfulness, because it is followed by a little 
swelling. A single drainage-tube suffices, except in large 
scrotal hernise. There is no need of keeping the tube in a 
long time ; it should be removed some time between the 
fourth and eighth days ; and thus the cure of a strangulated 
hernia does not generally take more than from eight to 
twelve days. 

In this way the operation is made with great ease, and with 
entire absence of concern as regards proximity to the perito- 
neum ; indeed, in my hospital services, I always give the 
students a good understanding of the operation, by making 
them put their fingers into the wound, and even into the 
peritoneum, behind the open ring, provided they have 
cleansed their hands in my presence. Sometimes there are 
seven or eight around me who make this deep examination, 
which has never yet, to my knowledge, resulted in any 
harm. 

Several times cases in which the intestine was injured and 
even perforated have presented themselves. Panas once had 
occasion to apply a ligature like the string of a purse to an 
intestine which had become gangrenous at one point ; then 
he reduced the hernia, and the patient made a good recovery. 

I have always taken advantage of the occasion for this 
operation to make that for radical cure, and whenever there 
are large masses of omentum, I cut them off, and reduce the 
one or more pedicles tied with catgut. 

I have generally made the sutures with silver wire, but I 
have also used catgut, and have very lately had an excellent 
result in the case of a woman, who was out of bed in less 
than three weeks after the operation. 

As regards the dressing, I would particularly direct the 
attention of the reader to the difficulties of applying it in the 
fold of the groin. We have to make it thick and to complete 



OPERATION FOR RADICAL CURE. 149 

it at the edges with boracic wadding or lint. The amount of 
discharge is so moderate that very infrequent dressings will 
be found sufficient. The early omission of the drainage and 
the use of catgut for sutures are favorable to rapidity of 
healing. 

In order to insure the maintenance of the radical cure, I 
always make the patients wear a bandage for some time after 
the operation. It seems to me that, since I have employed 
the proceeding indicated, the radical cure has been the rule, 
while, in my first operations, recurrence of the difficulty was 
most common. 

Radical cure of hernia. 

This operation will soon take its place in the rank of 
legitimate surgery, both on account of the security acquired 
by the employment of Listerism, and from the possibility of 
employing without hesitation convenient and really effica- 
cious methods. The publications on this subject are already 
numerous. 

One of the first and most brilliant of the published results 
was that of my friend and companion, Dr. Chiene, of Edin- 
burgh, who effected the radical cure of immense epiploic 
hernias. 

The essential steps of the operation are as follows : incision 
of the sac ; subdivision of the pedicle of the epiploic mass 
into little bundles, each of which is tied with catgut ; excision 
of the omentum below the ligature. This being done, the 
pedicles are reduced. The whole of the sac is resected, the 
neck is closed by deep catgut sutures close to the ring, then 
superficial silver sutures are inserted, and drainage effected 
as in case of strangulated hernia. Chiene has made this 
operation successfully several times already. 

I myself pursued this plan in taking advantage of a keloto- 



150 ANTISEPTIC SURGERY. 

my made for a left, strangulated, crural hernia, accompanied 
by an omental mass as large as my fist. I relieved the constric- 
tion, reduced the strangulated knuckle of intestine, divided 
the epiploic pedicle into seven fasciculi, excised the entire 
mass, and replaced the pedicle within the ring. Then I cut 
away all the sac, and sewed up the neck with deep silver 
stitches. The patient was cured in three weeks ; and when 
I examined her, several months afterwards, she had had no 
return of the rupture. The catgut threads had been cast out, 
which I attributed to the premature abandonment of the 
dressing ; the patient was not in my own service, and I did 
not personally superintend her case. Three months after, I 
did the same operation upon a woman sixty years old, who 
was up and about in three weeks, wearing a bandage. 

Dr. Henry O. Marcy, of Cambridge, Massachusetts, has 
published an interesting treatise, in which he recommends 
operating without opening the sac. The sac being exposed, 
he replaces it within the ring with his finger, and fastens it 
in place with catgut sutures, passing them at the level of the 
neck. This operation he has performed twice in cases of 
strangulated hernia and once in an uncomplicated hernia, 
with complete success in the first two, and partial in the 
last. 

The most complete publication is that of Professor Tilanus, 
of Amsterdam. He shows by statistics that the operation for 
radical cure, even when performed antiseptically, is not abso- 
lutely free from danger, and he thinks that it ought to be 
employed only in irreducible or otherwise complicated hernise. 
In performing it, he advises the excision of the sac, the suture 
of the deep parts about the neck, and a superficial suture. 
He has tried the plan of not making the patients wear a ban- 
dage immediately afterwards, but his experience was not 
satisfactory, and he now favors the use of the bandage. He 



UMBILICAL HERNIA. 151 

does not approve of complicated procedures, and considers 
the use of injections as insufficient. Tilanus's work reviews 
all the important facts which bear upon this subject, partic- 
ularly those brought forward by Czerny. 

The same dressings should be used as in strangulated 
hernia. It is a good plan to make a number of incisions 
about the ring, a sort of scarification. This, combined with 
complete excision of the sac, permits the deep suture to effect 
an approximation of surfaces which are raw and bloody. 
Drainage is called for, but should be dispensed with as soon 
as possible. The deep suture which includes the ring may 
be made either by tying the two ends and leaving them deep 
in the wound, or by bringing the two principal threads out and 
securing them on the skin, which is my method of doing it. 
The suture should be carefully watched, as it sometimes ex- 
cites swelling. The stitches are much more easily taken in 
inguinal hernia. 

Umbilical hernia affords an especial opportunity for anti- 
septic surgery. It is no longer a matter of such gravity as it 
was formerly, and the excision of the sac is particularly easy. 
We know that in ovariotomy, when there is a co-existent 
umbilical hernia, it is the rule to excise the sac and the ad- 
jacent skin ; it is a simple procedure for radical cure which 
should be used in cases of umbilical hernia. 

Professor Carl Rossander, of Stockholm, performed very 
nearly this operation for umbilical hernia in a child of two 
years, in 1878. He opened the sac, excised the omentum, 
ligatured the sac, retrenched it and the pouch of skin, and 
sewed up with catgut, using no drain. The cure was imme- 
diate ; and, several months afterwards, there had been no 
return of the difficulty. 



152 ANTISEPTIC SURGERY. 

Laparotomy for internal strangulation. 

The opening of the abdomen to seek for the seat of a 
strangulation, whether we are guided by the data of an exact 
diagnosis or proceed very much at random, has become an 
excellent operation, for the reason that, on the one hand, 
large abdominal incisions are no longer serious, and, on the 
other, even prolonged search under antiseptic protection does 
not tend to awaken inflammation. This is the opinion of 
almost all surgeons who are familiar with the antiseptic 
method, and antiseptic laparotomy has achieved numerous 
successes in England, Germany, and Denmark. 

My colleague and friend, Dr. Terrier, in 1877, made at the 
Bicetre a laparotomy for internal strangulation upon an old 
man of sixty-three years. In spite of his alarming condition, 
the patient was completely cured in ten days. 

Recently I assisted Dr. Terrier in a laparotomy on a young 
woman of twenty-one, two months after her accouchement. 
She had well-located pain of an unbearable character, vomit- 
ing, a pinched countenance, and low temperature. Both of 
us diagnosticated strangulation by a loop of peritoneum. The 
incision was made in the linea alba. There was bloody 
serum in the abdominal cavity. The operation was very 
laborious and occupied nearly an hour and a half. Dr. 
Terrier was obliged to pull out a large part of the intestines 
before he could reach the constriction, which was found in 
the true pelvis. It was lifted up on two fingers and torn, 
and the abdomen was rapidly sponged and closed. The 
patient recovered in a few days, and, after the operation, 
complained of no pain in her belly. In this case, as in the 
former, the spray was furnished by my apparatus. The 
operation was made in the common ward, without removing 
the patient from her bed. 



LAPAROTOMY FOR STRANGULATION. 153 

These two cases may be taken as remarkable types ; analo- 
gous cases are easily found to-day. Antiseptic laparotomy 
for invagination of the intestines has often been performed ; 
the gut having been unwound, the cure is immediate. 

We should also remember the beautiful operation of Studs- 
gaard, of Copenhagen, who, in a case where a glass vase had 
been put into the rectum and had passed into the colon, 
whence it could not be extracted through the natural pas- 
sage, incised the abdominal wall, opened the intestine, 
removed the foreign body, sewed up the bowel with catgut, 
returned it to the belly, and closed the external wound. The 
patient recovered rapidly. 

The antiseptic method has made this searching for foreign 
bodies a practical and, in difficult cases, a valuable resource. 

In operations of this kind, certain directions should be fol- 
lowed. To have them successful and rapid, we must make a 
bold incision in the abdominal wall, and I advise making 
it always in the median line. As I have remarked elsewhere, 
these large incisions give us a chance to search without hin- 
drance from the intestines, even when they are tympanitic. 
Several incidents in my own experience warrant me in mak- 
ing this assertion ; but I have never had better proof of it 
than in a laparotomy which I made on an old woman of 
eighty, who had an internal strangulation coincidently with 
an uncomplicated hernia. The tympanites was enormous. I 
made a large, median incision, and readily reached the con- 
striction. Unfortunately, such was the condition of the in- 
testine that there was no chance for a successful result ; but 
I had found an almost easy operation, where I had feared it 
would be difficult. 

The draining of a little carbolized water into the peritoneal 
cavity is not a matter of great moment; but, nevertheless, it 
is prudent to cover the edges of the wound with moist com- 

11 



154 ANTISEPTIC SURGERY. 

presses, which will prevent the too abundant entrance of this 
liquid into the abdomen. All the viscera which are exposed 
to the air ought to be scrupulously washed with the weak 
solution. The ligatures may be made of fine carbolized silk, 
or, better still, of good catgut. 

Finally, in the majority of cases, drainage is useless. We 
close the abdomen completely, as in ovariotomy after the 
pedicle has been dropped back into the cavity. 

Ovariotomy. 

It was obvious that ovariotomy would be happily influ- 
enced by the antiseptic method. I do not know who first 
made a complete application of it; perhaps it was Newman 
in 1872. Nussbaum, of Munich, seems to have been one of 
the first to practise it thoroughly, using the spray, bathing 
the peritoneum with the weak solution, and draining the ab- 
domen with a bundle of eight tubes inserted upright near the 
pedicle. Immediately his results, which had been no more 
than moderately good up to that time, became excellent; he 
cured eight patients in succession, a thing which had never 
happened to him before. Volkmann made an operation in 
1873. Howitz, of Copenhagen, began in December, 1875, in 
his seventy-seventh operation. He had been having a series 
of hopeless failures ; he adopted the method, and at once had 
nine consecutive successes. 

In Germany, ovariotomy never gave anything but moder- 
ate results until the antiseptic method was introduced ; and 
the most brilliant evidence of the advantages of Listerism is 
in the article of Schroeder {Berliner Klinische Wochenschrift, 
18, March, 1878) on fifty antiseptic ovariotomies, in which 
he shows that the mortality was reduced from fifty to twenty 
v per cent. 



keith's ovariotomies. 155 

The documents upon this subject are now very numerous, 
and it would be necessary to devote a considerable chapter to 
their mere enumeration, for almost every country contrib- 
utes some. I must content myself with pointing out two 
articles of capital importance, which are to be found in the 
British Medical Journal for the 19th of October, 18T8. 

The first is by one of the surgeons of the Samaritan 
Hospital, which has been made so celebrated by the opera- 
tions of Spencer Wells, and is entitled, Fifty eases of com- 
plete ovariotomy, with remarks upon six other eases of opening 
the abdomen, by Knowsley Thornton. The author, who was 
Professor Lister's interne before he became Spencer Wells's 
assistant, shows that, from the very day on which he adopted 
the antiseptic method, his operations were much improved, 
and while his first twenty-five cases gave seven deaths, that 
is, twenty-eight per cent., the following fifty, for the most 
part by the antiseptic method, gave four deaths, that is to 
say, eight per cent. 

True other article is^still more important, being from the 
Scotch Ovariotomist, Keith, who has, up to the present time, 
obtained the- most beautiful results known. He narrates how 
he tried the antiseptic method at first without the spray, and 
his results were less satisfactory than by his ordinary practice. 
He renounced this plan, and substituted the perfect anti- 
septic method, including the spray. Before that, the mor- 
tality in fourteen years had been one in seven, and, for the 
year immediately preceding, one in twenty-one. The first 
forty-nine cases with the full antiseptic method gave him two 
deaths, which occurred in the first eight cases. He had op- 
erated on forty-one consecutive cases without a death. The 
two fatal cases were of so exceptional gravity that he would 
probably not have attempted them without the antiseptic 
method. 



156 ANTISEPTIC SURGERY. 

In Keith's opinion, the method has diminished the mor- 
tality. The security which it gives warrants operation at an 
earlier date. Drainage is less frequently necessary, and may 
be more speedily dispensed with. Convalescence is more 
rapid. The operation is much easier, and the proceedings for 
the purification of the person and instruments are simpler. 
Finally, says Keith, the best proof that the spray is necessary 
in ovariotomy is my previous experience with the antiseptic 
method so many years without the spray. 

The application of the antiseptic method in ovariotomy 
may be made in two distinct conditions — where the pedicle 
is kept outside, and where it is returned to the peritoneal 
cavity. It is easily seen that the latter facilitates the appli- 
cation of the method. 

Ovariotomy is done in the ordinary way with a good steam- 
atomizer. All the catgut ligatures are cut short and left in 
the cavity. The pedicle is subdivided and tied with silk or 
catgut. Drainage is effected, as in the past, by an upright 
glass tube, through which the fluids may be aspirated from 
time to time. This tube should be capped with an antiseptic 
sponge well wrung out. Nussbaum has used a bundle of 
eight caoutchouc tubes for a drain, withdrawing one or two 
at each dressing. Vaginal drainage appears generally to be 
a bad proceeding. 

I have not had a large personal experience in complete 
antiseptic ovariotomy, having done it but three times. Two 
of these patients rapidly recovered ; the third, whose general 
condition was deplorable, rapidly sank and died. 

I have made one hysterotomy with ablation of both ovaries 
for a rapidly growing sarcoma. The patient was in a most 
satisfactory condition, both general and local, after the oper- 
ation ; but strangulation took place, and she died almost 
suddenly on the fifth day. 



OVARIOTOMY IN FRANCE. 157 

In France, the antiseptic method was not at first rigorously 
applied in ovariotomy. Lately, my colleagues, Terrier and 
Pe'rier, after having for some time employed only its princi- 
pal precautions, have adopted it in all its completeness. It 
is hard to determine the share of the method, for the success 
was great all through: twenty of Terrier's twenty-two cases 
were successful, and all of Perier's eight. Moreover, Pe'rier 
last year removed both ovaries and the entire uterus, dis- 
tended with an enormous myoma which filled the abdomen, 
necessitating an incision which extended almost to the ensi- 
form cartilage. The operation was thoroughly antiseptic, 
and the woman recovered without accident. 

In making an ovariotomy, the operator should take pains 
to keep any considerable amount of carbolized water from 
entering the abdomen, and, if any does, to sponge it carefully 
away at once. During the operation, compresses saturated 
with weak solution should constantly be used for the protec- 
tion of the incision and the viscera. Silk or catgut may be 
used for. ligatures. In an immense majority of cases, drain- 
age may be dispensed with. It is even dangerous, if the 
dressing is -not proper. Without drainage the dressing is 
extremely simple : above the protective, several layers of 
moist gauze ; then a very generous amount of dry gauze ; 
and over this a mass of wadding. The dressing rarely 
requires to be renewed, except in case of pain. 

It has seemed to us, as to Keith, that those patients who 
recover excellently have a little greater elevation of tempera- 
ture on the first day than patients used to before the method 
was adopted ; but that is common to all antiseptic operations 
where large surfaces are exposed. 



158 ANTISEPTIC SURGERY. 

Ccesarean section and Porro's operation. 

The antiseptic method has enabled us to revive the Cesa- 
rean operation in cities, and successful cases have already 
been published. 

Disinfection of the vagina and uterus is very difficult, and 
perhaps the security will never be absolute, but considerable 
gain may be made. In these cases, in addition to all the pre- 
cautions relative to the abdominal wall, the vagina should be 
washed out with repeated injections of strong carbolized 
water ; a compress, saturated with the weak solution, should 
be laid upon the vulva, and frequently renewed. 

The operation is like ovariotomy. The uterus is to be 
incised in place, and, after the delivery of the child and 
placenta, the wound is to be closed with sutures. This may 
be done with good, large catgut. It has been said that they 
cut out ; but it is probable that, in these cases, the thread 
was too fine, and particularly that the stitches did not go 
deeply enough into the walls. Abdominal drainage should 
only be made with short tubes, placed in the lower angle of 
the wound ; and it would be imperfect, if retraction of the 
uterus were to take place. According to circumstances, the 
drainage will be abdominal or vaginal. 

The minutest precautions must be observed with reference 
to micturition and defecation, especially in the first days. 
Thick tampons of gauze and even carbolized sponges, care- 
fully separated from the skin, may be employed with ad- 
vantage. 

I have had some experience in the operation of Porro, 
which is Cesarean section followed by excision of the body 
of the uterus. Last March, Tarnier performed it in the 
midst of students in the great amphitheatre of the Maternity, 
a place which is not considered healthful, to say the least. 



PORRO'S OPERATION. 159 

He requested me to take charge of the antiseptic manoeuvres, 
which were as follows: the preparation of the abdominal 
surface as for ovariotomy ; repeated vaginal injections with 
strong carbolic solution ; the application of carbolized com- 
presses to the vulva ; in the course of the operation, after the 
incision of the uterus, the very careful toilette of the perito- 
neum with carbolized sponges ; the application of a knot of 
iron wire to the pedicle ; scrupulous dressing with gauze. 
After the operation, a carbolized compress was kept upon the 
vulva. The healing was rapid ; the antiseptic dressing was 
not discontinued until the wound had become insignificant. 

It is much easier to attain perfect asepticity in this opera- 
tion than in Cesarean section, and this is certainly one of the 
greatest inducements to choose it. While nobody has known 
of a successful case of Cesarean section in Paris for a hun- 
dred years, the antiseptic method has given us success in an 
equally formidable operation in a hospital amphitheatre. I 
have nothing to add to the description of the precautions 
taken in ovariotomy and laparotomy, excepting the purifica- 
tion of the vagina. * 

Since this operation was first performed by Porro, of Pavia, 
in May, 1876, it has been made but seven times in France : 
once by Fochier, of Lyons, in February, 1879, mother and 
child being saved ; twice by Tarnier, of Paris, the mothers 
being saved, and the infants dead before the operation was 
begun ; and four times by myself, with the result of bringing 
into the world four living children, and saving two of the 
mothers. Of the infants, two are yet alive and well ; one 
was killed by criminal carelessness ; and the last, which was 
very feeble from its birth, died in four days. The two sur- 

1 The description of the author's four Porro's operations which fol- 
lows is taken from a report which he sent to the translator in April, 

1881. 



160 ANTISEPTIC SURGERY. 

viving mothers are in excellent health, and I presented them 
at the Academy of Medicine in March, 1880, when I reported 
all my cases. 

By a singular chance these four cases of extreme contrac- 
tion came under my observation in the space of two months. 
In each there was a rachitic pelvis, with a conjugate diameter 
of about six centimeters or less. 

The first patient was twenty-six years old, primiparous, one 
meter and a quarter tall, with a sacro-sub-pubic diameter of 
seventy-three millimeters — a typical rachitic case. During 
the last three weeks of her pregnancy I had her under my 
care at the Maternity. Labor began in the morning of the 
nineteenth of November, 1879, and the operation was per- 
formed in the afternoon of that day, every precaution having 
been taken. The bag of waters had not broken, there was a 
slight bloody discharge, and the cervix was effaced. An in- 
cision fifteen centimeters long was made in the median line, 
beginning a little above the navel, and the womb was quickly 
reached. A frightful gush of blood followed the cut into the 
uterus, but the section was rapidly completed, and a living 
child weighing twenty -seven hundred grams was removed. 
The placenta was then extracted, and the womb was drawn 
out of the abdomen by means of two cyst forceps which had 
been previously applied to the edges of the uterine wound. 
Two pins were passed through the lower portion of the 
uterus, an iron wire was put around below, and another 
between them, and both were drawn tight with the ligateur 
Cintrat. Then the body of the uterus, together with the 
ovaries and Fallopian tubes, was removed. The stump was 
touched with perchloride of iron and brought between the 
lips of the abdominal wound, which was then closed with 
one superficial and six deep sutures. The perfect Lister 
dressing was applied. The operation lasted three quarters of 



SUCCESSFUL CASES. 161 

an hour. The subsequent history of the case was very sim- 
ple. On the evening of the twenty-first, the highest temper- 
ature, 38.9° C, was reached. By the twenty-eighth, all the 
stitches had been removed, and then the pins were withdrawn. 
The pedicle disappeared on the second of December, and 
cicatrization was complete on the twentieth. In about six 
weeks the patient was completely cured. There is but 
slight abdominal protrusion, the cervix is large and movable, 
and she had sexual congress without accident two and a half 
months after the operation. In direct violation of orders, 
her child, when three days old, was carried from her cham- 
ber, the temperature of which was 23° C, to a very cold 
church to be baptized. It had previously been particularly 
well; but it immediately became ill, and died in thirteen 
days. 

The second of these women was in the service of Professor 
Potain, in the H6pital Necker. She was twenty-two years 
old, one hundred and thirty centimeters high, very rachitic, 
with a sacro-pubic diameter of, possibly, five centimeters. 
She had been in labor thirty-six hours, and the amniotic 
fluid had been discharged twenty-four. After having admin- 
istered chloroform for several hours to quiet her extreme 
excitement, I performed the operation at nine in the evening 
of the thirtieth of December, 1879. The os was dilated to 
the size of the palm, and labor was in full progress. I began 
the abdominal incision of sixteen centimeters well above the 
navel, and ended it at a greater distance from the pubes 
than in the preceding case. Considerable hemorrhage fol- 
lowed the incision into the uterus. The infant's shoulder 
presented, but it was pushed back, and the child was ex- 
tracted by the feet. It proved to be a fine boy, weigh- 
ing more than three kilograms, and immediately breathed 
well. The treatment of the wound was like that in the 



162 ANTISEPTIC SURGERY. 

previous case. During the subsequent history the only 
alarming symptom was an extraordinary acceleration of the 
respiration (fifty-five a minute) twenty-four hours after the 
operation. The temperature never reached 38° C. The 
wound was dressed on the fifth and again on the ninth days, 
the pedicle dropping out of sight on the second of these 
occasions. By the end of January, 1880, there remained 
only a very superficial ulceration. She began to get up in 
February, and has now been well for a long time. The heal- 
ing was so perfect that but little trace of the operation re- 
mains. The baby was confided to the care of one of the 
nurses, and is doing well. 

The other two operations were fatal. One was performed 
at the Maternity on the third of December. The woman 
died in thirty-six hours ; the child still survives. 

The final case was in my service at the Cochin, on the 
seventeenth of January, 1880. The sacro-pubic diameter 
was forty-nine millimeters. At first the patient was in very 
good condition; but she had a violent nervous attack four 
hours after the operation, and expired in twenty-three hours. 
The child lived three days. 

I believe that my operations demonstrate the desirability 
of making the abdominal incision at a higher point than has 
hitherto been practised ; for, by keeping the wound at a good 
distance from the pubes, perfect asepsis is much more likely 
to be accomplished. 

If great attention is bestowed upon the antiseptic precau- 
tions it is not necessary to have a special, absolutely pure 
apartment for the operation. One of my patients was oper- 
ated on and recovered in a badly ventilated chamber, which 
had been sometimes used for the isolation of contagious dis- 
eases. The essentials are seclusion, warmth, quiet, attention, 
incessant antiseptic precautions, and sufficient comforts. 



ABDOMINAL OPERATIONS. 163 

Hydatid cysts of the liver. 

The opening of large hydatid cysts of the liver has been 
done by Volkmann in the following manner : he incises the 
abdominal wall as far as the liver, and then applies the per- 
fect Lister dressing. Several days are allowed to pass, in 
which a slight inflammation excites adhesion between the liver 
and the abdominal wall, and then he can open the cyst and 
treat it with antisepticlnjections. 

A similar operation has been made in the case of a cyst 
which was very difficult to empty, by first performing resec- 
tion of a rib overlying the liver, and then opening the abscess 
at another time. 

Nephrotomy, gastrotomy, normal ovariotomy, splenotomy, etc. 

I merely indicate by name these cases of antiseptic ab- 
dominal surgery ; practically, the precautions which should 
be taken do not differ from those which we have pointed out 
in the before-mentioned operations. 



CHAPTER XX. 

Surgery of the Female Genital Organs. — Operations with 
Perfect and Imperfect Asepsis. — Obliteration of the 
Vagina. — Vesico- vaginal Fistula. — Perineorrhaphy. — 
Enucleation of Fibrous Tumors of. the Uterus. — Aseptic 
Accouchement. 

It is a matter of extreme difficulty to obtain perfect asepsis 
in the neighborhood of the anus, vagina, and urethra ; but 
yet, it can be achieved in some cases, while in others the 
attempt will be unsuccessful. Nevertheless, by following the 
precepts of the antiseptic method, the surgical interference is 
much simplified, suppuration is diminished or repressed, and 
septic accidents are less to be dreaded. This is not strictly 
Listerian surgery, and yet it is a style of practice which is 
inspired by Lister's teachings. So, without going into minute 
details, I devote this chapter to enforcing its importance upon 
the mind of the reader ; the special applications he will be 
able to make for himself. I will begin with those operations 
which may be strictly aseptic, at least for a time, and follow 
with those which are only partially aseptic. 

Obliteration of the vagina. 

It is well known that the operation of opening the hymen, 
the vagina, and the uterus, when the menstrual fluid has 
been dammed up behind an obstruction for months or years, 
is one of especial gravity. If the opening is made without 
the introduction of instruments or fluid into the vagina, pow- 



IMPERFORATE VAGINA. 165 

erful and frequent antiseptic injections diminish this gravity ; 
but fatal cases are unfortunately still common. In my opin- 
ion, the danger depends upon the immediate accidents, and I 
think that, if one can insure complete asepsis during the first 
few days, and the uterus has once been restored to its normal 
condition, the chance of accidents is only moderate. 

The plan which I proposed I have twice tried with success. 
It consists in carefully cleansing the adjacent parts, making 
an opening with all the precautions, establishing drainage, 
and applying masses of gauze and a mackintosh. The bowels 
are to be confined. Twice or thrice in twenty-four hours a 
probe is passed with all the desirable precautions, including 
the spray. No vaginal injections are made. After five or 
six days, when the womb has returned to its normal condi- 
tion, the severity of treatment may be relaxed, if the woman 
cannot endure the precautions any longer ; but if one can 
gain a few days, so much the better. Then the dressing is 
continued in the same way, but the patient is allowed to 
urinate and go to stool. But, in this case, vaginal injections 
of carbolized water are demanded, because the vaginal dis- 
charge immediately becomes odorous. 

On the fourth of March, 1877, 1 operated upon a girl of sev- 
enteen, whose abdomen had been growing large for two years. 
At the menstrual periods the pain was intense. The lower 
end of the vagina was about three centimeters from the sur- 
face, as was determined by rectal examination. The fundus 
of the uterus had risen up as high as the navel. At the time 
of the operation, there escaped a full wash-bowl of altered, 
tarry blood, and the discharge continued extremely abundant 
for the three following days ; but, with the precautions men- 
tioned, the liquid remained absolutely odorless. Thus it 
continued up to the fifth day, when, the uterus having re- 
sumed its natural size, the discharge was insignificant. The 



166 ANTISEPTIC SURGERY. 

strictness of the watch was abated, and from the next day 
the liquid had an odor. Abundant vaginal injections were 
then given twice a day with two-and-a-half per cent, carbolic 
solution, and the patient was well in three weeks, without 
having had any inflammatory complication. The menses 
were regularly established, and this young woman, who was 
married in November, 1878, was delivered without difficulty 
of a beautiful child on the twenty-fourth of September, 1879. 

In another case, the blood found an exit beside one of the 
labia majora, a little before the hour fixed for the operation. 
Nevertheless, I was able to apply an antiseptic dressing, 
and the first days passed as in the first case, without bad 
odor, without putrefaction of the confined fluid. At last, on 
the fifth day, I stopped passing the probe, and on the mor- 
row the discharge began to smell. The artificial opening 
was enlarged by an incision, and the patient recovered. For 
more than a year her catamenia have been regular. 

In such cases, the following method should be pursued: 
all the folds of the vulva, the parts covered with hair, and the 
entire anal region must be scrupulously cleansed with washes 
of strong carbolic solution ; under the spray, a free incision 
is to be made, as in the case of my first patient; the uterus 
is to be gently pressed, so that the blood will slowly drain 
away, and two large tubes are inserted side by side ; the 
gauze dressing should then be applied directly to the vulva, 
without the intervention of the protective. The mass should 
be thick, and, at the anus, should make a kind of barrier to 
divert the intestinal gas. Above the gauze the mackintosh 
is placed. The dressing needs to be often changed, for, in 
the first hours, it gets saturated with the fluid and easily 
becomes infected. It is a good plan to bathe the parts in 
strong solution at each dressing, but not to make injections. 
It should be remembered that the skin is more delicate in 



VAGINAL OPERATIONS. 167 

some individuals than in others, and, in any event, rubbing 
with cloths wet in strong carbolized water should be avoided. 

Vesico-vaginal fistula and ruptured 'perineum. 

In other operations upon the external genitals we have not 
the means of sheltering the parts as completely from germs 
as in the case of occluded vagina. Such are those for vesico- 
vaginal fistula and ruptured perineum. 

Great care should always be taken in the preliminary 
washings with carbolic water. It is well, before taking the 
sutures, to touch with the strong solution the surfaces which 
are to be brought together. There is advantage in employ- 
ing the antiseptic gauze and protective to afford complete 
and permanent protection to the wound. Boracic acid lint 
is very convenient material to form a kind of tampon for the 
vagina and its neighborhood ; but, in all these cases, the anti- 
sepsis will be only relative. 

Catgut has been a good deal employed both for vesico- 
vaginal-fistula operations and for perineorrhaphy. In the 
fistula cases its application is very easy, and we have the im- 
mense advantage of not being obliged to withdraw the 
thread. To make this suture conveniently, we should have 
catgut which is at once flexible, fine, and solid, as the most 
of the material in the market is not. 

In perineorrhaphy there is no especial advantage in the use 
of the catgut, except for the stitches which we take in the 
vagina, where they are absorbed without giving us any con- 
cern. Dr. Auguste Reverdin has reported two entirely suc- 
cessful cases, made five days after accouchement. He let the 
stitches take care of themselves. In one of the cases, four 
catgut sutures were taken in the vagina and five in the 
perineum. In spite of the most unfavorable circumstances, 
the union was complete. 



168 ANTISEPTIC SURGERY. 

The ingenuity of the surgeon ought to inspire him to apply 
the antiseptic method in these cases in such a manner as not 
to produce irritation or to injure the sutures. 

Enucleation of fibrous tumors of the uterus. 

Operations for the removal of fibrous tumors of the womb 
are rarely followed by serious consequences. It would al- 
ways be desirable to diminish the chances of peripheral in- 
flammation, and to reduce the more or less fetid discharges 
which follow the operation. 

The method which I recommend and have successfully 
employed is as follows: the vagina is washed with the 
weak carbolized solution, or the strong, if it can be borne ; 
after the operation, which is performed in any way the sur- 
geon may prefer, the vagina is again washed out with an 
abundant injection of the strong solution ; then there is placed 
upon the vulva a large compress, saturated with weak car- 
bolic water, and this should be frequently renewed. Instead 
of this compress, a generous parcel of antiseptic gauze may 
be used. 

In removing fibrous tumors from the womb, whether they 
are pediculated or not, I prefer the method of enucleation. 
I could cite three operations of this kind, in which antiseptic 
precautions were adopted. The first two were in the ser- 
vice of M. Siredey, and one of the tumors was intra-mural. 
The vaginal injections were made with the weak solution. 
Both patients recovered without accident. The third I 
operated on in this city, with the assistance of Dr. Barborin, 
of Joinville. The discharge was extremely fetid before the 
operation. The strong solution was used for the injection, 
and the dressings were made as I have advised above. The 
odor disappeared almost immediately, and the recovery was 
very rapid. 



LISTERIAN MIDWIFERY. 169 

I ought to add that, in all operations which I make at the 
upper part of the vagina, even simple scarifications of the 
neck, I use carbolized injections. As a complement to these, 
we may employ antiseptic tampons ; but, as they are liable 
to excite irritation in wounds of the cervix, I usually con- 
tent myself with vulvar compresses, even after serious opera- 
tions. 

Aseptic accouchement. 

If there is any traumatic condition in which asepsis would 
seem to be more desirable than in any other, it is evidently 
parturition ; and it is plainly a matter of duty to endeavor to 
afford protection in this state by the antiseptic method. Un- 
fortunately, those who have made the trial seem to have 
taken into consideration only the infectious element in the 
development of puerperal accidents ; and have not thought 
of the harm which may come from traumatic injuries and 
untimely contact. I confess that I have no confidence in 
constantly repeated vaginal and even uterine injections, or in 
the antiseptic plugging of the vagina ; and I have a partic- 
ularly poor opinion of injections in the days immediately 
following delivery. 

So, after having made various experiments and seen the 
very mediocre results of these violent efforts, I have come to 
the conclusion that, in parturition, the antiseptic surgeon 
should be satisfied with one thing, and that is absolute sur- 
gical cleanliness. 

Here are the rules which I have followed for nearly two 
years in my service in the Cochin Hospital. Not only is 
every medical officer required to keep his hands clean, but, 
in addition to this, he is strictly forbidden to make a vaginal 
examination of a woman, or to pass from one examination to 
another, without washing his hands in the weak solution. 

12 



170 ANTISEPTIC SURGERY. 

The only lubricant employed is five- or ten-per-cent. car- 
bolized oil. After delivery, the vulva is washed with the 
weak solution,*or, if the case requires, with the strong, and 
is then dressed |with a compress saturated with the weak 
solution. If the vulva or vagina has suffered any serious 
injury, the wound is washed with the strong solution. Im- 
mediately before operations, the vulva and the surrounding 
parts are bathed in the same. After serious operations, which 
have necessitated the introduction of instruments or hands 
into the vagina or uterus, I generally inject the vagina or 
even the womb with the two-and-a-half-per-cent. solution, 
once or several times in succession, taking great care that all 
the fluid returns. Sometimes I have used the strong solution 
in such cases. 

Last year I performed version in a case of shoulder presen- 
tation, occurring in the service of M. Siredey. The foetus 
was distended with gas like a balloon, and I practised evis- 
ceration. The womb was enormously distended with gas 
and fetid liquids, and there seemed to be but small chance 
for the woman's surviving the operation. I rinsed out the 
uterine cavity with the weak solution several times. The 
patient recovered without any difficulty. 

The question arises as to whether antiseptic precautions 
can be pushed any further. The spray would seem to have 
some power in purifying the atmosphere of the ward, but it 
is not necessary. However, I have used it in wards where 
I had other patients. 

Injections made daily or every other day have been greatly 
extolled ; but, according to my experience, they may be pro- 
ductive of fatal irritation, and I prohibit their employment in 
my service, except in very rare cases. 

Finally, there is a very curious fact. In the great majority 
of cases the lochia are fetid ; but all that is needed to abolish 



RESULTS IN OBSTETRICS. 171 

this odor is to carefully wash the vulva with carbolic water, 
and to keep its opening constantly covered with a moist, car- 
bolized compress or with antiseptic gauze. Almost invariably 
it is the contact of the air that makes the lochia offensive — 
a very interesting fact in its bearing upon the putrefaction of 
secretions at the natural orifices. 

If I have to use tampons, I employ only those that are 
thoroughly carbolized. I often practise a sort of incomplete 
plugging after labor, arid I have never seen any unfavorable 
results from it. 

The employment of these means has given me excellent 
results. At the Cochin Hospital in 1878, there were seven 
hundred and seventy deliveries, serious operations being per- 
formed in a good number of them. There were five deaths, 
of which only two were on account of puerperal diseases, the 
other three comprising a consumptive, who was admitted in 
the very last stages, and died twenty-one hours after her 
accouchement ; a patient who came from the medical service 
with acute pericarditis, and lived only four hours; and a 
woman in convulsions, who expired two hours after entering. 
Result : not a death from operation ; gross mortality, 0.694 
per cent. ; puerperal mortality, 0.232 per cent. 

The most remarkable circumstance about all this is that I 
had my students examine all the women in labor and all the 
subjects of operation every morning, and I made them prac- 
tise the vaginal touch during the operations ; and yet the 
mortality of the patients on whom I operated was lower than 
that of women in ordinary confinement. 

My results in 1879 have not been as good. In the first 
place, the report is damaged by some cases of women who 
were brought to the hospital in a moribund condition ; but, 
besides these, there were some deaths which, in my opinion, 
might have been prevented if the method had been practised 
with sufficient rigor. 



172 ANTISEPTIC SURGERY. 

Up to to-day, the twentieth of November, the confinements 
number six hundred and eighty-five. Eleven deaths have 
occurred, giving an apparent mortality of 1.60 per cent. But 
it would be unjust to the hospital to charge the following 
deaths to its discredit : three women brought in with rupture 
of the uterus, who were promptly delivered by craniotomy, 
embryotomy, and the application of the forceps respectively ; 
one woman, dying in eclampsia when she was admitted ; and 
one consumptive, with pulmonary lesions, tuberculous peri- 
tonitis, etc., which speedily killed her. In reality, there have 
been but six deaths due to accouchement among the patients 
who were treated, and this reduces the mortality to 0.89 per 
cent. 

Moreover, in the six there were two vicious insertions of 
the placenta, cases exceptionally bad in spite of the medium. 
These women, admitted in wretched condition, exhausted 
with bleeding, were unable to rally, and rapidly succumbed 
after delivery. 

The actual mortality, therefore, of the institution is four, 
or 0.58 per cent. — three women delivered naturally and one 
with instruments. 

These two years have presented a considerable number of 
difficult cases. In 1879 alone there were five vicious inser- 
tions of the placenta, cases of eclampsia, and other complica- 
tions of pregnancy. 

The operations performed in these years were as follows : — 

Application of the forceps, sixty-two, without a death ; 
besides one in the case of a woman brought in from the city, 
with a rent in the womb, who died shortly after. 

Version, fifteen. 

Operation on account of abnormal attachment of the pla- 
centa, one ; the patient died. 

Induced labor, eight ; no deaths. 



DIMINISHED MORTALITY. 173 

Artificial delivery, eleven ; one death from puerperal ac- 
cidents. 

Cephalotripsy, four ; no death. In one other case there 
was evident rupture of the uterus, and the child's head was 
crushed to facilitate delivery ; the patient died two hours 
afterward. 

Embryotomy, one ; cured. One other embryotomy was 
performed to deliver a woman who was dying from rupture 
of the womb, and who survived the operation but one hour. 

Thus, leaving out the artificial deliveries, the mortality 
from traumatism is really nothing, and consequently less than 
in the normal confinements ; and yet there were ninety-one 
cases — certainly a respectable number. 

In passing, I wish to call attention to the three cases of 
rupture of the uterus, brought in from the city, and to the 
case of convulsions, almost dead when admitted. They give 
us an idea of the numerous ways in which the obstetrical 
mortality of the city is falsely represented at the expense of 
the reputation of the hospitals — a subject upon which I 
shall have something further to say at the proper time and 
place. 

Certainly, we must consider it a fine result to have re- 
duced the puerperal mortality to a point where there are but 
six deaths in one thousand four hundred and fifty -five cases, 
or, in other words, about 0.41 per cent. For my part, I de- 
clare myself satisfied with this result for a beginning, and for 
the further reason that I am able to give a large amount of 
instruction without danger ; but I am of opinion that much 
better results can be obtained. In my service I achieved 
much less than I sought. A crowd of details still escape me, 
eluding my vigilance. I have an absolute conviction that, of 
the three deaths which occurred this year, at least two could 
have been avoided, although I cannot say precisely in what 



174 ANTISEPTIC SURGERY. 

respect we were at fault. It is impossible to give the reader 
in detail all the desiderata which I observe. And yet, the 
attainment of the same results elsewhere requires the abso- 
lute reform of the habits of the chiefs of the services, of the 
administrative officers, and of the students. In lying-in 
women more than in any other wounded patients is it indis- 
pensable to apply the antiseptic principle everywhere. 

I regret to see large sums of money devoted to the estab- 
lishment of hospitals which are not really needed. Improve- 
ments can be made. With sufficient room and antiseptic 
cleanliness, the condition of the old and bad institutions can 
be immensely ameliorated, and it can be made even perfect 
without any great expenditure in newly invented luxuries. 
M. Tarnier's pavilion at the Paris Maternity shows how new 
structures can be built. For my part, I believe in still greater 
simplicity, and that there are serious inconveniences in rigor- 
ous isolation ; and I am of opinion that there are many local- 
ities which can be made very useful by attending to the 
following conditions : — 

Abolish pure water in the lying-in service, and abandon 
the use of all germ-bearing epithems ; disinfect all the linen 
with heat, disinfect everything extemporaneously with car- 
bolized water ; do not disturb the genitals of the woman, 
even with antiseptic intent ; insure her repose ; supply her 
with sufficient nourishment ; keep her quiet at the last of her 
gestation ; exact antisepsis of everybody who comes near the 
patient. 

A thousand useless precautions are taken, and this is neg- 
lected. If an interne understands sufficiently how to make 
himself clean, he can devote himself to all his occupations, 
make the post-mortem examinations which are a part of his 
duty, dissect, and examine patients without danger. If he is 
neglectful of antiseptic precautions, it will be best to quaran- 



A PLEA FOR CLEANLINESS. 175 

tine him, or else he will always be coming in and poisoning 
the lying-in patients. The kind who never make a necropsy 
often kill a great many more people than the anatomists who 
are careful about antiseptic precautions. 

In Paris, all the habits of the students are in need of 
reform. I do not blame them ; it is physically impossible for 
them to be surgically neat in the hospital. Reforms are 
demanded in the interest of the patients and in the interest 
of instruction, which ought to be made compatible with the 
safety of the sick. Hardly more than a single word is needed 
to indicate these reforms. At present, not only is nobody 
compelled to wash his hands, but it is almost impossible to do 
it in a hospital, so poor are the facilities. 

A liberal and intelligent administration, anxious to comply 
with the wishes of the surgeons, has made it easy for us now- 
a-days to practise antiseptic surgery in the hospitals of Paris ; 
but we do not think the government inclined to favor in 
every way the practice of antiseptic midwifery. 



CHAPTER XXI. 

The Ligation of Vessels. — Arteries and Veins. — Radical 
Cure of Varix. — Varicocele. 

The ligation of vessels appears in an entirely new light: 
there is no elimination of a foreign body, no necessary division 
of an obliterated vessel, no irritation of the denuded trunk. 
At the very outset one can see what modifications this in- 
volves in our method of treatment. 

In the case of ligatures designed to close gaping vessels in 
a wound, we put in our sutures without any anxiety as to the 
thread which remains behind. No argument is necessary to 
prove the immense superiority of this procedure over all that 
have been proposed to replace the ligature — torsion, forci- 
pressure, acupressure — even if we look merely at the security 
obtained. So remarkable is the special peculiarity of the car- 
bolized catgut that it can maintain itself even in a wound 
which is not dressed antiseptically, although this is not con- 
stant. In my first edition I reported the experience of Keith, 
who employed it in ovariotomy without the antiseptic method, 
and of Oliver Pemberton, who used it to ligate the femoral 
without the Lister dressing. 

The ligature of vessels in their continuity, made with all 
the rigor of antiseptic surgery, may be especially quoted as 
giving results of the most valuable character. On this point 
Lister draws his convictions from his experience, which is 
already very extensive. The wound closes over the knot of 
catgut, which does not cut the artery. Obliteration of the 
artery takes place without division. The catgut supports 



CATGUT FOR LIGATURES. 177 

the vessel, at least in the first days, and until it is absorbed. 
These facts render it probable that we shall be able to tie 
successfully the great vessels, whose division so uniformly 
induces secondary hemorrhage. It is also likely, as certain 
observations of Lister and his followers seem to show, that 
an artery, the femoral, for example, may be safely tied close 
to a large branch. As the artery is not divided, secondary 
hemorrhage will not ensue. 

In this class of operations antiseptic surgery requires 
nothing more than ordinarily. Nevertheless, it is well to 
recommend the use of catgut of large size and tested strength. 
I have seen reports of accidents, which seemed to me to be 
caused by the poor quality of the material. There is so much 
bad catgut in the market that I insist upon the importance of 
this direction. The older the thread is, the better it is. 

It has been objected to the catgut ligature that the thread 
rapidly breaks down, but I have never comprehended the 
force of the objection. To give way at the moment when 
the ordinary thread begins to cut the tissues could not seri- 
ously be considered as supporting them, and that process be- 
gins almost immediately after the application of the ligature. 

The catgut divides the inner coats of the artery exactly as 
the silk does, and repair takes place just as it does when the 
silk injures the external tunic, that is to say, when the silk 
does not leave a part of the vessel intact to sustain the inner 
tunics which have been cut. What does it matter if there is 
a giving way when the thread is absorbed ? After forty- 
eight hours there is no chance of hemorrhage in the wound. 
Some experiments upon animals have convinced me of the 
identity of the mode of repair of vessels. 

Nobody at the present time questions the importance of 
ligation of arteries in their continuity ; it has been performed 
successfully a great many times upon almost all the large 



178 ANTISEPTIC SUKGERY. 

vessels. Of course, it will be understood that the general 
principles of drainage and of suturing will guide us in the 
after-treatment of these cases. 



The radical cure of varix. 

Although formerly we hesitated to apply ligatures to veins, 
at the present time we can do it with perfect safety, as the 
thread excites no inflammation, no suppuration around it. 

Lister reports a case in which he sutured the lips of a 
gaping wound of the axillary artery with very fine catgut. 
It is much simpler and more common to tie the entire vessel. 
This method has made great progress possible in the surgery 
of veins. Confident of this, I have employed simple ligation 
as a means of radically curing varicose veins, making my first 
operation in the early part of 1876. 

The method of procedure is as follows : the large venous 
trunk is freely, though not extensively, uncovered, and a 
sufficiently strong thread of catgut is passed under it. A 
double knot is then tied with moderate tightness, and the 
ends of the thread cut short. One or two points of silver 
suture are taken in the skin, a small rubber tube being in- 
serted through an orifice left in the most dependent portion 
of the wound, which is then dressed in the usual manner. 

This operation has suggested itself to several surgeons. 
Schede performed it after me, adding the division of the vein 
between two ligatures. Risel, of Halle, tied in two places, 
and excised the intervening portion of the vessel. Annan- 
dale published in 1879 the report of a case in which he 
removed from the left leg of a young man an enormous mass 
of varicose veins, measuring forty centimeters in length, 
twenty-five in breadth, and fifteen in height. His patient 
made a perfect recovery, and was still well four months after- 
wards. 






VARICOSE VEINS. 179 

This excision may be treated with drainage or with com- 
plete closure, according to the extent and situation of the 
wound. 

Annandale has practised ligation of veins for a long time. 
He reported a case of varicocele treated in this way as early 
as 18T4. 

This new application of old methods, now revived with 
modern security, can be utilized in a great many cases, by 
following out the general indications. 



CHAPTER XXII. 

The Treatment of Abscesses. 

Acute abscesses. 

The treatment of abscess is certainly one of the most curious 
applications of the Lister method, for it is very remarkable to 
see the cavity of an abscess, even though it be very large, 
stop suppurating the moment it is opened, and close, as one 
may say, by first intention, so rapidly does the adhesion of 
its walls take place. 

The openings into an acute abscess need not be nearly as 
extensive as by the ordinary method ; but, if the patient is 
anaesthetized, I prefer a large incision, which I afterwards 
reduce by taking two or three stitches. 

After the evacuation of the pus, it is useless to make an 
injection, if the cavity is small ; but if it is very large, it is 
necessary to throw into the cavity some carbolized water, 
strong or weak, according to the region involved, and to 
cleanse it very carefully. Then the stitches are taken, one 
or two drains put in upright, and the dressing is applied in 
such a way as to moderately compress the walls of the cav- 
ity. If the discharge is abundant, the protective is useless. 

The suppression of the purulent discharge, which is fol- 
lowed by one of a sero-purulent character, is a surprise at the 
first; but the rapidity of the healing is much more aston- 
ishing. 

I have now practised this procedure more times than I can 
enumerate; but I can cite some large abscesses which have 



ANTHRAX. 181 

healed up with amazing speed. I cured in this way, in ex- 
actly eight days, a huge abscess in the sheath of the right 
carotid of a young man. In the service of M. Millard, at 
Beaujon, two years ago, I opened a large perinephritic ab- 
scess in a young woman. It was a phlegmon, with its point 
of departure in a uterine lesion, the causation of which I made 
out by the assistance of my researches upon the lymphatics of 
the womb. This patient, confided to the care of Dr. Tapret, 
then the interne on duty, was cured in eight days and with 
three dressings. At the Lariboisiere I opened by a simple 
puncture an enormous abscess in the axilla of a young man, 
and ten days after there was not a trace of suppuration. 

When abscesses are small, the cure is effected much more 
rapidly, and in regions where the scars are not covered by 
the clothing, this is a very important fact. In regions like 
the breast, where the abscess is the point from which new 
inflammations push out in every direction, we are much less 
likefy to have a series of abscesses. The secondary purulent 
sinuses disappear. Cicatrices on the borders of great ab- 
scesses no longer come to weaken people whom, otherwise, 
months of suppuration condemn to suffer permanent retrac- 
tions. 

This result is particularly noticeable in whitlows and 
phlegmons in the palm of the hand. In these cases it is well, 
after having freely opened the abscess, to wash it thoroughly 
with the strong solution. As the parts have generally been 
covered previously with cataplasms, it is necessary to take ex- 
traordinary care in the bathing which precedes the operation. 

The same remarks will apply to the treatment of anthrax. 
As regards the pain, for the relief of which it is usual to 
recommend the heat of a cataplasm, a hypodermic dose of 
morphine will soothe it more completely and constitute a 
desirable substitute for the common epithem. 



182 ANTISEPTIC SURGERY. 

Finally, I insist upon this fact : it may be useful, after the 
incision is made, to inject the cavity in order to completely 
empty it of pus ; but this should by no means be repeated 
afterwards, as it will retard the healing process. 

In some cases, where the pouch is infected anteriorly, 
where it has been impossible to maintain the aseptic condi- 
tion, copious washings of the cavity with carbolized water 
are required. The necessity of thoroughly evacuating the 
injected fluid must never be forgotten. It is almost always 
in cases of large pelvic or perirectal abscesses that poisoning 
occurs. I have seen a pelvic abscess the injection of which 
gave rise to slight toxic symptoms. There was need of a 
counter-opening, which being made, the injections were con- 
tinued without further difficulty. 

Where there is intolerance of carbolic acid, a weak solution 
of chloride of zinc is of great service. 

Cold abscesses. 

In these, the modification in the walls requires to be more 
complete, and it is well either to inject the cavity with an 
eight-per-cent. solution of chloride of zinc, or to scrape the 
inner surface with the curette of Yolkmann. I have had 
o-ood success with both methods. 



o 



Congestive abscesses. 

The treatment of these is certainly one of the most difficult 
applications of the antiseptic method, but it is also one of the 
most valuable. Up to the present time they have been noli 
me tang ere, and the surgeon has approached them only with 
extreme repugnance. 

If they are opened antiseptically the first result is that the 



TREATMENT OF ABSCESS. 183 

evacuation of the fluid is not followed by inflammation of the 
pouch. A serous matter continues to be discharged. If 
the dressing is kept on a long time, the cavity is finally re- 
duced to a narrow fistula, and the primary lesion, after elimi- 
nation of the sequestra, may heal spontaneously. The opening 
should be sufficient for very easy drainage and for the passage 
of a tube. In cases of migratory abscesses which have started 
from a distant point, as the vertebral column, it is better to 
simply open them without washing them out. Where the 
original seat is less remote, and the pouch is but moderately 
large, the injection of carbolized water on the first day may 
be advantageous. Lister quite generally puts in a horsehair 
drain in these cases. 

As the treatment is long, it is necessary to carefully avoid 
making the opening in the neighborhood of any source of 
putrefaction, such as any open suppuration or a natural cav- 
ity. If this condition cannot be fulfilled, it will be wiser to 
defer the opening a while. 

The result of the operation in this class of cases is that the 
cavity is reduced in size and the walls to some extent adhere 
to each other. If the abscess depends upon extensive bony 
lesions, the sequestra will be thrown off, and the healing will 
take place slowly, without fever, without any surgical com- 
plication. When the osseous disease is accessible, the incision 
of the abscess will, of course, be followed by the operation 
which is necessary for a cure. If the involvement is only 
superficial or periosteal, affairs progress more rapidly. 

The treatment of these abscesses requires extreme exactness 
in the application of the dressing; for, if there is any lapse, 
the healing will be retarded not a little, and often the termi- 
nation may be fatal, as in cases where the abscess is opened 
without the precautions. These recommendations are all the 
more necessary, as the treatment may be extremely pro- 






184 ANTISEPTIC SURGERY. 

tracted. This is one of the cases in which it is especially 
desirable to complete the dressing at its periphery with sali- 
cylic wadding or boracic-acid lint, so as to effectually prevent 
the entrance of air. 

Finally, I have had occasion in some large abscesses to 
make injections of a ten-per-cent. solution of chloride of zinc. 
I have made this addition to the method when I was not sure 
of the quality of the dressing and of the antiseptic precau- 
tions. In the case of a young man who had an immense 
abscess in the dorso-lumbar region, I made two of these 
injections. After the second, he had a pleurisy, with which 
the injection was certainly not unconnected. He got over 
his pleurisy very well, and in the mean time the purulent 
cavity perfectly closed, and did not re-open in the ten months 
during which I kept him under observation. 






CHAPTER XXIII. 

Empyema. — Hypogastric Lithotomy. 

One would expect the operation for empyema to give exactly 
the same results as the opening of abscesses in general, and 
yet it is undeniable that often the dressing is insufficient to 
prevent the infection of the cavit}'. More than ordinary pre- 
cautions are necessary, as is well shown in a case reported by 
John Duncan in 1878, where the insufficiency of the antisep- 
tic atmosphere was perfectly evident. 

I think that, in many cases, one may dispense with injec- 
tions of the cavity, at least for a long time, and jet he is 
generally led to make them. My advice in such cases is to 
distrust carbolic solutions, which are very rapidly absorbed 
by the pleura, and to use instead injections of boracic-acid 
water or even a weak solution of chloride of zinc. 



Hypogastric lithotomy. 

Many authors have thought supra-pubic lithotomy prefera- 
ble to the perineal operation, and it seems as if the antiseptic 
method was destined to dissipate the objections made to the 
former. The facts are not yet sufficiently numerous for us 
to judge; they are almost all derived from cases in infants, 
who, on account of their tender years, present a condition 
peculiarly favorable for hypogastric lithotomy ; and yet it is 
clear that this is the direction in which progress is going to 
be made. 

13 



186 ANTISEPTIC SURGERY. 

In his thesis in 1873 Zayas Bazan described an operation 
which he saw Professor Lister make upon a boy of fourteen 
years. The peritoneum was opened, and then closed with a 
suture. The bladder was sewed up, then the abdominal 
wall, and a drain was inserted under this suture. The recov- 
ery was rapid. 

In an article in Hygiea, in 1878, Carl Rossander made a 
long plea for epicystotomy. In the last congress at Amster- 
dam, Dr. Van Goudaever, of Utrecht, read an interesting 
article, in which he recommended supra-pubic lithotomy in 
all infantile and many adult cases. 

While, in perineal lithotomy, it is almost impossible to 
make use of the precautions of the antiseptic method, it is 
entirely practicable in the supra-pubic operation. 

All the steps of the operation are the same. Nearly all 
authors advise complete suture of the vesical walls with cat- 
gut. The suture of the abdominal walls should be incom- 
plete, an opening being left at the lowest portion for the 
introduction of one or two drains. The dressing around the 
penis ought to be made with great care. Lister thinks it 
desirable to complete it with boracic lint, making a sort of 
sheath for the organ. According to most authorities, it is 
better to practise catheterism than to let an instrument re- 
main all the time in the bladder. 



CHAPTER XXIV. 

Castration and Operations upon the Testicles. — Cure of 
Hydrocele by Volkmann's Method. 

Operations upon the scrotum require peculiar precaution 
on account of the mobility of the parts, which necessitates 
the application of a generous quantity of wadding around the 
ordinary gauze dressing. The conformation of the region, 
also, and the character of the skin call for much more care in 
washing than any other parts. However, we should avoid 
letting strong solutions of carbolic acid remain too long in 
contact with the penis, lest severe irritation be produced. 

Castration, 

The use of the catgut ligature makes this operation very 
simple. It may be done in two ways, either by tying the 
cord in a mass, or by dividing it into two or three portions 
and ligating each separately. It has been proposed to isolate 
the vessels and tie each by itself ; but this involves unneces- 
sary trouble. 

The catgut does not separate, and the extremity of the 
cord is not thrown off. The wound is closed like any other, 
a drain being introduced at the most dependent part, and 
withdrawn after a few days. 

I removed a very large sarcomatous testicle from a patient 
a while ago, and, in seventeen days, the only trace of the 
operation was a linear scar. 

The decortication or simple opening of hematoceles may be 



188 ANTISEPTIC SURGERY. 

effected by a similar procedure, without subjecting the pa- 
tient to any appreciable risk. 

Hydrocele. 

It is well known that, for some years, Volkmann has prac- 
tised simple incision in treating hj^drocele, following with the 
suture of the tunica vaginalis. Sometimes a drainage tube is 
employed, and sometimes not ; but the former method is the 
more prudent. There are no phenomena of inflammation and 
no suppuration. The time required for the cure is rather less 
than after the injection of iodine, ten or twelve days, and no 
ill consequences have been observed. 



CHAPTER XXV. 

Operations on Tendons and their Sheaths. — The Opening of 
Large Cysts. — Club-foot. — The Suture of Tendons. 

The opening of the sheaths of tendons causes suppuration 
no more than the opening of the peritoneum or the articula- 
tions. It may be done in many different ways. The opening 
of large compound ganglia of the wrist, formerly so greatly 
dreaded, has become almost common. The cyst is thoroughly 
emptied, and closed up with sutures, and the patient quickly 
recovers. 

Club-foot. 

The subcutaneous method of operating on tendons entirely 
loses its importance in the presence of Listerism, and nothing 
is easier than operating with everything exposed to view, as 
it can be whenever any difficulty arises. There are plenty 
of cases already on record in which the division of tendons 
has been followed by immediate union. 

The suture of tendons. 

This operation, formerly performed frequently, is now done 
with catgut in much more favorable conditions. It has 
already been made so many times in different circumstances 
that it is quite superfluous to cite cases. The rules for the 
application of catgut are the same as those to be followed in 
using silver wire, only that no provision is required for the 
cutting of the stitches. 



CHAPTER XXVI. 

Trephining the Skull. 

In a monograph on trephining by the antiseptic method, I 
have given my reasons for considering this operation no lon- 
ger grave, but one which may be made without apprehension. 
It has now been performed a good many times by the Lister 
method. The only things about it which require especial 
mention are the desirability of careful drainage, as always in 
large wounds of the head, and the necessity of a scrupulous 
preparation of the surrounding parts, on account of the diffi- 
culty of freeing the scalp of greasy matters which pollute it. 
In a case of hemorrhage of the superior longitudinal sinus, 
Professor Lister carefully plugged the entire cavity in the 
skull with catgut. The bleeding was arrested, and there was 
no impediment to recovery. 






CHAPTER XXVII. 

The Treatment of Ulcers. — Epidermic Grafting. 

Epidermic grafting, -as practised by my colleague, Dr. 
Jacques Reverdin, is greatly facilitated by the Lister method, 
indeed, just in proportion to the extent to which we render 
the ulcers aseptic and, consequently, favorable soil for the 
growth of the grafts. If the ulcer is not of very long standing, 
after it and its immediate neighborhood have been carefully 
bathed in carbolized water, it will be sufficient to wash its 
surface with an eight-per-cent. solution of chloride of zinc. 
It is then covered with a large protective, and a dressing of 
boracic acid is applied. After two or three days, we cleanse 
the ulcer with a boracic solution, and proceed to the grafting. 

If the granulations on the ulcer are well formed, there is 
an advantage, before applying the zinc, in cleaning the sur- 
face with Volkmann's curette, for the purpose of removing all 
exuberant growths, and then washing, and letting the wound 
rest for a few days under the protective and a boracic dress- 
ing, the latter being renewed daily. We wait some days that 
we may not be impeded by the bleeding, and then proceed 
to graft in the following manner, described in a note which 
Dr. Reverdin has been so kind as to write me. 

The almost absolute certainty of obtaining immediate union 
and the simplicity of the progress of wounds under the Lister 
dressing ought to induce all surgeons to employ it in epider- 
mic grafting and in transplantations, both dermo-epiclermic 
and dermic. Lister himself, in a lesson upon the boracic acid 






192 ANTISEPTIC SURGERY. 

dressing, devotes to the subject several pages, of which I pre- 
sent a resume. The skin on the inner aspect of the fore-arm 
is cleansed with the strong solution of carbolic acid. Then a 
little piece of it, including hardly more than the epidermis, 
is removed, and being placed upon the thumb-nail, moistened 
with a drop of boracic solution, is cut up into minute frag- 
ments of the size of the head of a pin. These bits are, one at 
a time, placed upon the granular surface of the ulcer, which 
has been, up to this point in the procedure, carefully covered 
with a piece of muslin soaked in boracic solution. Now only 
as much is uncovered at a time as is necessary for the de- 
positing of each graft ; and, as fast as this is done, the part is 
immediately covered again with a little piece of protective 
which has been dipped in a boracic solution. The operation 
being completed, a large protective is spread over the entire 
surface, over this the boracic lint, and the whole is secured 
by a bandage. This dressing is allowed to remain for two or 
three days, and is then removed. One must content himself 
with cleansing the surroundings of the ulcer, and avoid touch- 
ing the granulations themselves, lest he destroy the adhesions 
which the grafts have contracted. Very soon an epidermic 
zone will be seen developing around each of the grafts ; and 
the same dressing is continued until the breach of surface is 
entirely closed. The insignificant wound of the fore-arm is 
at the same time dressed with protective and boracic lint. 

In some cases, Lister substitutes for the lint a piece of 
cloth spread with boracic acid salve ; but every graft must 
be shielded from contact with this preparation by a bit of 
protective. 

It is probable that many surgeons have used the boracic 
or carbolic dressing in grafting. Reverdin has employed the 
antiseptic method in such cases a number of times with con- 
spicuous success. 



GRAFTING. 193 

Volkmann, of Halle, also has used the antiseptic method 
in these cases. He generally takes large grafts and places 
them side by side, so as to cover the whole surface as with a 
mosaic. This, however, would hardl}' be accomplished in 
surfaces of any great extent, except in a hospital, where the 
integuments of recently amputated limbs can be utilized. 

Schede, of Berlin, proceeds thus : the ulcer is scraped with 
a Volkmann spoon, so as to obtain a bloody surface entirely 
freed from dirt ; strong, disinfectants are applied ; then dermo- 
epidermic or dermic flaps of some size are put in position, 
side by side, like a mosaic ; and the antiseptic dressing is put 
on. The success is generally complete, the ulcer being closed 
in a few days. Schede applies the dressing in the following 
manner: the grafts being in place, he takes a large bandage 
of antiseptic gauze, spreads it over the wound, and presses it 
down, thus squeezing out the blood, which, passing through 
the meshes of the gauze, is stanched ; then he rolls the ban- 
dage around the limb, and covers it in with the Lister dress- 
ing, omitting the protective. 

It will be seen from what precedes that there are several 
methods of grafting. By strict attention to these directions, 
we are sure to obtain results far superior to those formerly 
observed. 



CHAPTER XXVIII. 

Ophthalmic Surgery. 

The Lister method has been employed in ophthalmic sur- 
gery, and with a certain measure of success ; but the question 
of the best antiseptic has somewhat impeded its progress. In 
most cases, indeed, the eye will not endure an irritant anti- 
septic, and so recourse to boracic acid has been advised, or, 
after having taken all the antiseptic precautions, the employ- 
ment only of topics which are aseptic and imputrescible, like 
vaseline, but not really antiseptic, in the proper acceptation 
of the term. 

But carbolic acid has been employed ; and Dr. Rossander, 
of Stockholm, published in 1878 and 1879 the results of his 
operations. He washes the patient's face, and his own hands 
and instruments in carbolic water, and uses the spray in 
cataract operations, dressing with antiseptic gauze. In this 
way he made twenty-seven cataract operations without a case 
of suppuration either of the cornea or of the entire eye. Up 
to that time nothing like this result had been seen in that 
hospital. 

At the last congress at Amsterdam, Snellen read an im- 
portant paper which proved the utility of the following pro- 
ceeding : the preliminary washing of the field of operation 
and of everything which is to touch it in one-per-cent. car- 
bolic water, and the cleansing of the instruments in alcohol, 
should be observed in any operation upon the cornea. In 
such cases, the use of the spray presents decided difficulties, 



OPERATIONS ON THE EYE. 195 

and is successfully replaced by a current of air purified with 
carbolic acid. For an antiseptic and occluding dressing, it 
suffices to employ pieces of cloth saturated with vaseline and 
bits of purified cotton. Irritant antiseptic preparations, which 
augment the secretion of the conjunctiva and palpebral 
glands, ought not to be used. 

In an interesting article in his ophthaltnological review 
(November, 1879), Galezowski shows how he has put in 
practice the principles of the method. In a general way, he 
employs as an antiseptic a one-tenth-of-one-per-cent. solution 
of carbolic acid. The eye-washes are more frequently made 
with boracic acid. In addition to these, he uses only pieces 
of dressing previously disinfected. These precautions have 
already given excellent results. All these precepts are good ; 
and yet the method can be much more closely followed. In 
the first place, all the general precautionary measures, relat- 
ing to the surroundings of the patient, the washing of instru- 
ments, hands, etc., should be taken just as for other operations, 
with the strong solution. 

Operations involving the transparent media will not permit 
free washing with carbolic acid, but a boracic solution, even 
the concentrated, is perfectly well borne. The spray may be 
used, provided the spray -producer is sufficiently removed, and 
a weaker solution than usual employed. 

Only that dressing will be antiseptic which effects occlu- 
sion, and, for this purpose, the only substance which is en- 
tirely unobjectionable is the boracic lint. I have used it in 
this way, and, for these cases, I prefer it to the carbolized 
gauze. According to circumstances I use it dry, or saturated 
with an aqueous solution of boracic acid. 

Operations upon the conjunctiva require about the same 
precautions against the irritant action of a powerful anti- 
septic. But if the eye is destroyed, as in enucleation, or if the 



196 ANTISEPTIC SURGERY. 

operation is outside of the eye, for example, autoplasty, the 
carbolic acid resumes its place in our esteem. Nevertheless, 
I advise its employment in connection with that of boracic 
acid. For example, in enucleation I freely wash the cavity of 
the orbit with the strong solution, and then dress with boracic 
lint. I used to put under the lid the classic wad, making it 
of boracic lint ; but now, I think it much better to do nothing 
of the kind, and simply place a boracic dressing outside, 
keeping it there until cicatrization is perfect, which is usually 
but a short time. 

For little wounds about the lids, I recommend the employ- 
ment of boracic ointment spread on fine cloth, putting over 
it either a mackintosh or a layer of boracic lint, according as 
a wet or dry dressing is desired. 

It will be seen that, by following these directions, the ap- 
plication of the antiseptic method in ophthalmic surgery is 
possible and even easy. It will be noticed, indeed, that here 
we are not menaced with great quantities of fluids putrefying 
upon the dressing, and so our antisepsis is continually fresh. 
But it must not be forgotten that it is almost impossible to 
absolutely purify the sulci of the conjunctiva. Boracic acid 
and vaseline are the best agents to employ either singly or 
together. 

We all know how desirable the entire absence of sup- 
puration is in ophthalmic surgery, and understand that the 
attainment of this end ought to be sought with unremitting 
zeal. 



CHAPTER XXIX. 

Influence of Listerism upon the Healthfulness of Hospitals. 

One of the chief advantages of the method is its favorable 
influence upon the salubrity of hospitals. All the operations 
which I have mentioned were performed in hospitals with 
absolute safety. It was in a hospital that Lister made his 
great demonstrations of his method ; and in the wards of a 
hospital I myself have opened joints and serous cavities, and 
dissected veins, without any fear of accident or contamination 
from the media. 

Every wound is instantly shut up in an antiseptic atmos- 
phere, which is probably even purer and more healthful than 
mountain air. Of course, this is no reason for neglecting 
hygienic rules and seeking for bad hospitals, for it is always 
wiser to have as few and as insignificant foes to contend with 
as possible ; but it is a reason for defying infected media, if 
need be, and for using existing hospitals with proper pre- 
cautions. 

If the method is constantly employed, it exercises a 
beneficent influence upon the general salubriousness of the 
service. The action of perpetual emanations of carbolic 
acid is obviously favorable. Soon everything becomes im- 
pregnated with it ; even the drain-pipes at last cease to emit 
any putrid odor. This was the experience in my own ser- 
vice, where all possible pains had never succeeded in disin- 
fecting a certain sink in the obstetric ward ; but now that 
we are constantly throwing carbolized water into it, the odor 



198 ANTISEPTIC SUKGEKY. 

has entirely disappeared without any one's troubling himself 
about it. 

I have such confidence in the efficacy of these means that 
I am perfectly convinced that, by combining thorough car- 
bolic pulverization and washes, we might clearly rid of their 
baneful influences the lurking-places of epidemics. To estab- 
lish the correctness of this view would require a far greater 
number of facts than I can contribute ; and yet I have had 
experience in rooms where patients have sickened and died of 
puerperal fever, erysipelas, and other such diseases, and, after 
I had employed the spray and washings, no evidences of con- 
tagion appeared. This limited observation of mine is incon- 
clusive, but it is in a direction in which it is worth while for 
others to follow. 

The spray is a valuable method of impregnating anything 
you please ; and, by using it in connection with the purifica- 
tion of cloths and garments, by means of superheated air, we 
are destined to attain results the entire importance of which 
nobody can foresee. 

If the antiseptic method makes hospitals healthy for the 
present, it makes them so for the future. Whoever desires 
to profit by all the results of the method should make its 
application as extensive and as general as possible ; and day 
by day he will find his work made easier by the progressive 
purification of the media in which he performs his opera- 
tions. 

Finally, let us not lose sight of the fact that the method is 
of advantage to the surgeon and his assistants in greatly 
diminishing their chances of meeting with accidents. This 
comes from their living in a purified atmosphere and having 
their fingers constantly impregnated with the substance which 
is most powerful in neutralizing every kind of septic matter. 
I am aware that this suggestion may not be considered chiv- 



PEOTECTION TO THE SURGEON. 199 

alrous, and sometimes one would decline to entertain it ; and 
yet it seems to me to be important, for our assistants pay a 
cruel tribute to wound complications by the lesions which 
they contract in the wards ; and I am thoroughly convinced 
that, with the antiseptic system, this heavy burden will be 
lightened. 



CHAPTER XXX. 

Carbolic Acid Poisoning. — Carbolic Eczema. 

A great cry has been raised about the toxic properties of 
carbolic acid, and its speedy condemnation has been pre- 
dicted, although positive facts on the subject are so ex- 
tremely rare that it is even now impossible to study it with 
any great satisfaction. Kuster has investigated it more care- 
fully than anybody else, and Nussbaum, in the second edition 
of his book upon the antiseptic dressing, has an excellent 
chapter on the subject. 

Undoubtedly carbolic acid is toxic ; physiologists have 
shown upon animals that it acts like a poison. And yet it is 
employed in enormous doses upon human beings without ac- 
cidents or annoyance. The discoloration of the urine, which 
turns green and black, headache, and sometimes gastralgia, 
are the most common phenomena of the toxic state produced 
by it. In some cases, which are infinitely infrequent, sud- 
den collapse has been observed, a kind of sideration, with 
loss of consciousness, small pulse, and cold surface. A few 
of these cases have terminated fatally, but the most have 
recovered. 

Some individuals evidently have a peculiar susceptibility 
to the acid, of which I have seen some remarkable illustra- 
tions. Poisoning may undoubtedly occur from the injection 
of absorbent cavities from which the return of the liquid has 
not been provided for. It is very curious that, in the hands 
of those who have practised antiseptic surgery most — Lis- 



SUSCEPTIBILITY OF CHILDREN. 201 

ter, Volkmann, Saxtorph, and myself — nothing like this 
has ever occurred. Nussbaum, who has reported a remark- 
able case, points out how accidents may be avoided in these 
cases. 

Cases in which strong solutions have been injected into 
the areolar tissue around the rectum have proved fatal. I 
have seen patients with abscess of the iliac fossa and with 
empyema display transitory phenomena of poisoning, which, 
however, were easily dissipated. 

Prudence should be exercised in certain regions, and we 
ought probably to take into account some cachectic states ; 
but especially is age a matter of moment. Very young 
children are singularly susceptible to the action of carbolic 
acid. 

For a long time I have thought that erythema of the but- 
tocks, so common among new-born infants who are attacked 
with diarrhoea, was probably parasitic and amenable to car- 
bolic acid. One day last year, finding some babies in this 
condition in my service at the Cochin Hospital, I ordered a 
dressing consisting of a bit of fine cloth saturated with ten- 
per-cent. carbolized oil. The effect was excellent and speedy ; 
the nurses in charge of the children were amazed, and, in- 
stead of following my directions, that evening they conceived 
the unhappy thought of completely enveloping the lower 
limbs and bodies of four little unfortunate wretches in a 
large compress soaked in carbolized oil. At my visit next 
day I found these babes with pinched features and cold 
skins, vomiting, and with diapers stained black by the urine. 
The discovery of the unfortunate dressing readily explained 
their condition. Two of them died; the other two slowly 
recovered, and, strangely enough, were completely relieved 
of their erythema. 

I have continued to treat cases of this kind with carbolized 

14 



202 ANTISEPTIC SURGERY. 

oil, taking care to repress so excessive a display of zeal in the 
nurses, and no other accident has ever occurred. I mention 
the occurrence to show how very rapid the absorption of the 
acid may be in very young children, and that, notwithstand- 
ing this, it may be used with proper precautions. 

We must always remember that, like all other active 
agents, carbolic acid has certain undesirable properties, for 
which we must be constantly on our guard. 

In cases where we are obliged to leave injected fluids in an 
absorbent cavity, we must avoid the employment of strong 
solutions, or even substitute chloride of zinc for carbolic acid. 
When, in patients with wounds, the urine continues black, 
nausea arises, and gastralgia and headache persist, we must 
either lessen the doses or discontinue the use of the acid. 

But we should neither dispense with this powerful agent, 
nor make such assertions about its dangerous properties as is 
done in a report in the Centralblat f. med. Wissenschaften 
(7th September, 1878), in which it is related that poisoning 
occurred on account of a utero-vaginal injection, the liquid 
having passed into the peritoneum. 

The most perilous region as regards the action of carbolic 
acid is the perirectal, the most of the serious cases having 
been, as was previously remarked, those in which injections 
were made into the areolar tissue of this locality. 

It would be well, also, to avoid the excess in employing 
carbolic acid in which certain imitators of Lister indulge, 
offsetting their lack of precision in the observance of his 
directions by an extraordinary misuse of the antiseptic. 
After having observed these modes of operating, one cannot 
escape the conviction that the danger in using carbolic acid 
is extremely small, for no harm comes from this unwarrant- 
ably lavish employment of it. But that is no good reason for 
following such an example. 



TREATMENT OF POISONING. 203 

There is one other point which it is necessary to take into 
account — the quality of the acid. In France, our acid, 
even the ciystallized, is very bad smelling, and contains some 
toxic impurities ; but I have every reason for believing that, 
if a perfectly pure article is used, such as may be obtained 
from certain drug establishments which purify it themselves, 
the chances of accident are infinitely reduced. 

Theoretically, the sulphate of sodium is admitted to be 
the antidote to carbolic acid, and, in case of poisoning, Nuss- 
baum recommends the following prescription : — 

Sulphate of sodium 5 grams. 

Distilled Avater 150 " 

Syrup of raspberries 25 



a 



Of this two spoonfuls are to be taken every two hours. In 
cases of profound collapse, he especially advises artificial 
respiration. 

Carbolic eczema. 

Most cases of this affection result from holding the spray- 
producer too near the part operated upon. Cases in which 
the skin cannot endure carbolic acid at all are very rare. 
I have reported the case of a young man one of whose toes 
I amputated. He had so severe an eczema on the dorsum of 
his foot that I was forced to use the boracic acid instead. 
In fact, boracic acid is our best resource when we require an 
antiseptic which is entirely free from irritating properties. 



CHAPTER XXXI. 

Objections to the Antiseptic Method. 

The great success of Listerism, its achievements, so almost 
incredible from the point of view of received ideas, its prac- 
tice, so profoundly modifying the common course of surgery, 
naturally aroused lively antagonism. Antiseptic surgery 
was scarcely invented before violent war was made on it, 
from which the amenities of science were to a large extent 
excluded. From the very beginning, Lister's invention was 
disputed. In a curious article (Lancet, 1867) the illustri- 
ous Simpson attributes this discover}?" to all surgeons suc- 
cessively, at the same time declaring the method to be 
absurd and bad. Since then there has been written no dia- 
tribe which is either better or worse. 

When Lister had succeeded in proving that he claimed 
neither the discovery of carbolic acid nor the surgical em- 
ployment of antiseptics, but an ensemble of measures for anti- 
septic protection, for the defence of the organism by definite 
means, then discussion was directed to the principles, the 
nature, and the mode of action of the dressing. 

It was alleged that there was nothing new in it ; it was 
only a variety of dressings by occlusion. It is sufficient, 
however, to have seen the dressing but once, or to have 
attentively read a description of it, to become convinced that 
it is not an occlusion dressing. 

Others, better informed, recognized in it a variety of in- 
frequent dressing, and generally went back to the celebrated 
descriptions of Magatus in 1616. But the dressing is infre- 



OBJECTIONS. 205 

quent only to those who do not know how to appty it. In- 
deed, it is necessary to renew it very soon after the opera- 
tion, and one can rarely avoid a renewal within the first 
twenty-four hours. After this, the dressings become infre- 
quent only in proportion to the length of time which has 
elapsed since the operation. Are not these indications ex- 
actly opposite to those of the infrequent dressing ? 

Others still have argued, a priori, that the dressing could 
be of no use, because the micro-organisms counted for noth- 
ing in the causation of accidents ; that putrefaction is accom- 
plished independently of them ; and that, at most, they are 
but a product. It is even added, as a general thing, that the 
wounds which have putrefied the most are most exempt from 
accidents. 

I shall not discuss this argument here. It is perfectly cer- 
tain that the more perfect the defence against germs is, the 
better are the results of surgical operations. Under the 
Lister dressings, the micro-organisms are very rare and of a 
low grade of vitality. 

Not only do we not deny that wounds heal even though 
they be infested with micro-organisms, but we believe that 
the explanation of the fact is to be found in the power of 
resistance possessed by the healthy tissues and in the variety 
of the organisms, some destroying others. 

But if all this carried no conviction, if the theory were 
utterly false, the practice remains, and some other explana- 
tion of its results must be sought. A chemical theory might 
be advanced, but there are no facts to support it. Under the 
influence of well-applied antiseptic protections, the repair of 
wounds is metamorphosed. 

As far as the putridity of wounds is concerned, there are, 
indeed, surgeons who do not take pains enough to avoid it, 
but there is none who goes so far as to seek for it for the 



206 ANTISEPTIC SURGERY. 

sake of putting himself in accord with pretended scientific 
theories. 

Still others think that the general condition determines the 
fate of the patient who undergoes an operation : that he will 
recover if this is good, will die if it is bad. But the sur- 
geons who are most resolutely antiseptic in their ideas do not 
question the large part played b}^ the precedent condition of 
the organism ; in their opinion, even, that which proves the 
excellence of the method is that the influence of the state of 
the system loses a great deal of its importance, as repair be- 
comes so easy, and we dare to operate upon patients whose 
general condition would, but for Listerism, make us hesitate. 
An eminent master, who for a long time has devoted great 
attention to the influence of constitutional states, Professor 
Verneuil, emphatically expresses this opinion. 

Some other authors have been willing to admit that the 
method possesses some virtue, but this they ascribe to its an- 
tagonism to contagion, although Lister has not thought of 
this contagion. One must be very little acquainted with the 
surgeon and very ignorant of his method to advance this 
argument. It will suffice to have read my description to see 
that his object is to avoid something very different from con- 
tagion. 

More direct objections to the practice have been made, 
which constitute, in the minds of some authors, insurmount- 
able obstacles to its progress. Those who have made these 
criticisms have a poor understanding of the method — some- 
times none at all. 

It has been especially alleged that it seriously complicates 
the operations. A good spray-producer does not interfere in 
any way, and it would be childish to consider the other 
precautions as impediments. 

It is asserted that the dressing is difficult, tedious, necessi- 



A PAINLESS DRESSING. 207 

tating the presence and assistance of the chief of the service, 
that it is distressing and painful to the patient. As far as all 
this is concerned, I can say that I have never yet seen a good 
interne who did not apply the dressing rapidly and well ; and 
this is the more to be expected, as the dressings are strik- 
ingly similar in all cases. As there are fewer of them to 
make, it is perfectly plain that, in the long run, a patient 
requires much less time and attention than if he were 
dressed by any other method. 

The dressings are not painful, because they are not un- 
clean, because they do not torment the wounds by frictions 
and bathings, and especially because they do not excite any 
inflammatory action. And, furthermore, carbolic acid does 
not cause pain, as alcohol does, for example. Far from this, 
we know that it actually has anaesthetic power. Above all, 
with the spray, we can perform operations which are not 
very painful upon infants without anaesthetizing them. I 
have, indeed, made several operations without using chloro- 
form, and the patients have evidently suffered very little. 
At the Saint Louis Hospital, Laitler is at the present time 
employing the carbolic spray to produce anaesthesia of the 
skin in cases of violent pruritus. He was led to pursue this 
course by the remarks made by several of us at the Surgical 
Society upon the anaesthetic property of carbolic acid. 

Great objection has been made to the dressing on account 
of its costliness — a consideration of some importance in hos- 
pital service. I am prepared to assert that this is a remark- 
able exaggeration, and I have good reason for knowing, as, 
during the first six months, I dressed at my own expense all 
the patients on whom I operated. I privately imported from 
Edinburgh all the materials, when, too, they were very high- 
priced. I found the expense of the pieces necessary for the 
seven dressings, after an amputation of the leg at the upper 



208 ANTISEPTIC SURGERY. 

third, to be about two dollars and forty cents. This patient 
was healed in twenty-four days, and was able to leave the 
hospital on the thirtieth. In Nussbaum's excellent work 
I find an estimate of the pieces of dressing which he con- 
siders necessary in a thigh amputation, and, reckoning on 
the same basis, fifteen dressings would cost about five dol- 
lars. Since that time the price of the materials has been 
greatly reduced, so that, if one does not waste the pieces, 
as I have often seen done, the dressing is, in reality, quite 
inexpensive, far more economical, indeed, than most of the 
dressings employed to-day in hospitals, where alcohol almost 
always plays an important role. 

It may be added that the patients do not suffer, have no 
fever, enjoy their food, require no costly medicines, and have 
no need of especial attentions. But, above all, the rapidity 
of healing is extraordinary ; and, were its only advantage the 
abridgment of the patient's stay in the hospital, the method 
would be a great piece of economy. In his very remarkable 
book upon antiseptic surgery, Nussbaum shows that the sub- 
jects of amputation, by the shortening of their sojourn, cost, 
at the rate of fifty cents a day, from seventy-five to one hun- 
dred dollars less than formerly. It is easy to see that a great 
saving is made in the Paris hospitals, also, where the cost per 
diem is about fifty-three cents a patient. Each dressing at 
the highest price costs only from twenty to thirty-five cents, 
and the abbreviation of the stay in the hospital varies be- 
tween fifteen days and three months. The objectors to the 
method say that carbolic acid is irritant, and insupportable 
to the patient and the surgeon — an argument reproduced 
within a month at the Surgical Society. It is necessary, to 
start with, to have a clear understanding as to this word 
" irritant." If they mean that carbolic acid is caustic, and 
that it attacks the epidermis of the operator, thus making it 



AN ERROR CORRECTED. 209 

a little disagreeable for him at times, the statement is true ; 
but, if they mean that the acid irritates the wounds, that it 
excites inflammatory complications, it is false, at least in the 
case of any man who knows how to use it. Indeed, it is 
strictly forbidden to let the carbolic acid remain in contact 
with the wounds, with tissues in the course of repair ; but its 
temporary contact with a wound causes no irritation. Like 
all other disciples of Lister, I have washed with it the most 
sensitive tissues — the- peritoneum, the synovial membrane 
of the knee-joint, the tissues of the orbit, the dura mater — 
and I have never seen any of the phenomena of irritation. 
If any one does see them, it is because he has failed to follow 
the precepts which I have laid down. 

The dressing has been accused of favoring hemorrhage, 
and Demarquay has been particularly strenuous upon this 
point. The value of his observations is indisputable ; but as 
he has evidently fallen into an error here, I dwell a moment 
upon this point. It is true that carbolic acid is not hemostat- 
ic, and irrigation during an operation may rather favor the 
discharge of blood than check it ; but, for my part, I see no 
harm in that, for I am not averse to leaving in the wound as 
many ligatures as may be necessary to check this bleeding, 
tying veins as well as arteries. If secondary hemorrhage 
comes on, the operator must take the blame of it. Once I had 
such a case, in which profuse bleeding occurred after eight 
hours, entirely due to the fact that I had neglected the liga- 
ture of an important artery. Furthermore, we should re- 
member that the majority of operations upon the extremities 
at present are made with the application of the Esmarch 
bandage, or, at least, with a rubber ring around the upper 
part of the limb. This method, too generally adopted, is the 
great cause of secondary hemorrhages, and I have long be- 
lieved that the Esmarch bandage is far from being indispens- 



210 ANTISEPTIC SURGERY. 

able, except in a few cases, such especially as the search for 
a divided vessel, and the destruction of diseased portions of 
bone. A better means is needed, by which we can make less 
compression and produce less paralysis. The modification 
designed by my colleague, Dr. Nicaise, gives, in this respect, 
very satisfactory results. 

When the blood is well stanched, even if a little oozing 
still continues, the dressing may nevertheless be applied, 
light compression being employed. The discharge soon 
ceases, and the blood which escapes under the flaps does not 
hinder union. 

Other objections are of more importance. The odor of 
carbolic acid is disagreeable to some patients ; but I have 
rarely heard any serious complaint. 

The odor is more distasteful to the surgeon, because it 
impregnates his hands and his garments. If the acid is of 
good quality, this odor is less penetrating, and one may lessen 
its effects by various means. I am convinced that some other 
substance will be discovered equally good for washing the 
hands. 

Carbolic acid is sometimes irritant to the skin, and, in such 
a case, that which is of poor quality should be thrown away. 
Very rarely it awakens under the dressing a sort of eczema 
in people who are especially susceptible. The substitution 
of boracic acid easily remedies this difficulty. This irritation 
is more seriously disagreeable for the surgeon's fingers, which, 
being often wet with the strong solution, become harsh and 
rough, and are also the seat of annoying prickling. By taking 
care, this inconvenience may be partially avoided. To me, 
these are the only serious objections to the method, and I 
certainly do not find them sufficient to induce me to throw 
it aside. 

With still more reason do I find myself completely insen- 






INCONSISTENT OBJECTORS. 211 

sible to the objection of those who consider these surgical 
complexities inadmissible, who think that all surgery may 
be done with a bistouri and a bit of charpie, provided there 
is a stream of water in the neighborhood. This does not 
prevent them from planning hospitals which cost millions, 
and inventing cunningly devised instruments, which are very 
expensive for a single patient ; and, besides, they do not 
neglect to comfort their patients with costly medicines, pro- 
vided that all this does not deviate too much from approved 
usages. Then, after all, the patients who have been operated 
on with the bistouri and bit of charpie, in the hospital or 
even in the city, will have first to escape the actual dangers 
to which they are exposed, and then, in the most favorable 
circumstances, will be obliged to devote two or three months 
to the cicatrization of a wound which ought to be healed 
in fifteen davs or three weeks. 



CHAPTER XXXII. 

The Employment of Various Means when the Elements of the 
Antiseptic Method fail. 

To make this chapter exhaustive, it would be necessary to 
review all the substances proposed in the last ten years, and 
this simple examination would assume frightful proportions. 
It is unnecessary, however, to undertake this task, for the 
ingenuity of the surgeon will be able to meet the emergen- 
cies which arise when the ordinary means fail. It will be 
sufficient for him to bear in mind the following precepts : — 

First, Emollient epithems of various kinds are nests all 
ready for micro-organisms. 

Second. So-called pure water is often loaded with enemies, 
as Pasteur has so well demonstrated. Therefore, the use of 
epithems and pure water should be abandoned. 

Third. Carbolic acid is now so common that aqueous solu- 
tions can be made almost anywhere. 

Fourth. All antiseptics of the same family may be em- 
ployed, as borax, alum, tannin, sulphate of zinc, chloride of 
zinc, and such other agents. 

Fifth. Among the vegetable substances easily found in the 
fields, the green rind of the walnut, the walnut-leaf, oak- 
bark, afford decoctions which are sufficiently antiseptic in 
media which are not very dangerous. Tar is a substance of 
the very greatest worth. 

Solutions of carbolic acid in glycerine and especially in oil 
are of peculiar value, since the acid, when dissolved in these 
substances, is scarcely irritant, and a wound may be dressed 



SUBSTITUTES. 213 

with a twenty-per-cent. oily solution without excessive irrita- 
tion. Nevertheless, it is better to use solutions of less 
strength, as the more powerful lay one liable to toxic acci- 
dents. Thus, dressings with ten- or even five-per-cent. car- 
bolized oil are of very great service where frequent renewal 
is demanded. 

Wadding impregnated with five- or ten-per-cent. carbolized 
glycerine makes a valuable dressing. Even in an antiseptic 
hospital, when patients -enter with abundant suppuration, it 
performs important service. 

I used often to employ, especially in dressing patients 
operated on for strangulated hernia, layers of agaric saturated 
with weak carbolic solution. In other cases, I used charpie 
soaked in this solution, always observing the other precau- 
tions of the method, and covering the dressings with an im- 
permeable ; in suppurations I had thus a veritable cataplasm. 

In using vaseline or boracic ointment, one can easily follow 
out the principles of the method in simple cases. 



CHAPTER XXXIII. 

Formula for preparing the Materials employed in the 
True Lister Dressing. 

Carbolic acid. 

It is well to remember that there is a much wider choice of 
antiseptics than most of us have been accustomed to suppose. 
Professor Lister has not simply introduced carbolic acid into 
surgical practice ; he has invented a method which demanded 
the employment of the best antiseptics. After a great many 
trials, he has selected several which he has found useful. 
But, up to the present time, he has found no agent which is 
as valuable as carbolic acid for the habitual destruction of 
micro-organisms and for its action upon recent wounds. It 
cannot be said to be the best in every case, and for certain 
purposes Lister does not use it. He recommends other sub- 
stances in cases where the method cannot be rigorously 
applied. I am quite certain that the surgeon who, after 
having become familiar with the principles of the method, 
attentively studies the chapter on its practice, will be able, 
even though he cannot obtain the materials for the per- 
fect Lister dressing, to institute an antiseptic treatment 
which will always give favorable results, because the first 
attempts of the master himself, imperfect as we must consider 
them, constituted a great advance in surgery. 

The employment of carbolic acid presents indisputable and 
undenied disadvantages, which, however, are compensated 
for by advantages which are not less indisputable. Its odor, 
causticity, and poisonous properties are objections, as we 



PHENOL. 



215 



have already seen ; and I would remind all who contemplate 
using it that, in spite of the progress of industry, it is still 
burdened with a multitude of impurities. We should never 
employ the uncrystallized acid ; and there is some choice 
even among the crystallized specimens, for they are liable to 
contain various alkaloids, which, more than any other sub- 
stances, impart to it harmful properties. That which has 
most transparency and least odor has as powerful antiseptic 
qualities as any, and thcfewest disadvantages. 

The carbolic acid which combines these conditions is the 
product which is known in England as absolute phenol, and 
possesses the additional merit of being so much more soluble 
that a five-per-cent. aqueous solution can be made without 
the addition of alcohol. 

The disadvantages of carbolic acid may be remedied by 
associating it with other substances, one or another being 
chosen according to circumstances. For example, being vol- 
atile and very soluble in alcohol, it is given up by the liquid 
with great ease, indeed, we may say immediately. Thus 
the alcoholic solution is caustic and may furnish rapidly large 
quantities of the acid, when an extensive and powerful appli- 
cation is necessary. In water, the acid is a little more fixed, 
and thus the aqueous solutions are more manageable and are 
very widely used ; but even water parts with the acid so 
speedily that these solutions are bad agents for permanent 
dressings. 

In order to insure the solution of the common varieties of 
the acid, it is always the rule to add alcohol ; but as little 
as possible should be used, for, if there is a considerable 
proportion of alcohol, these solutions really become a little 
irritant. 

Some little care should be devoted to the preparation of 
the aqueous solutions. They should be made some time 



216 ANTISEPTIC SURGERY. 

before they are to be used, as, after standing a while, any 
undissolved globules may be more easily detected, and the 
solution will then be filtered ; for, if these globules be 
allowed to come in contact with the skin, they will produce 
a disagreeable burn. 

I have many times compared the effects of very pure and 
of impure carbolic acid. One-to-forty solutions of the former, 
in permanent contact with the tissues, cause no incon- 
venience ; solutions of the latter of the same strength some- 
times produce vesication. 

In order to avoid the disadvantages arising from the addi- 
tion of alcohol, I dissolve the acid in glycerine, and then add 
the water without alcohol. Gtycerine dissolves the acid 
more perfectly and rapidly than alcohol does. The propor- 
tion required is the same as that of alcohol. Solutions thus 
prepared are much less caustic and less disagreeable to 
employ than the others. They may be used for all purposes. 
It is true that, when they are used for the production of the 
spray, the tubes are more easily clogged ; but this incon- 
venience may be avoided, and we have the advantage of a 
much more perfect cloud. 

Aqueous solutions. 

The following are the formulae for the most commonly 
used solutions. In order to keep the nurses from making 
any mistake in them, I am accustomed to color the strong 
solution red. 

Strong aqueous solution, red. 

Carbolic acid crystals .... 50 grams. 

Alcohol . 50 « 

Water . 1,000 " 






FORMULA. 217 

Weak aqueous solution. 

Carbolic-acid crystals .... 25 grams, 

Alcohol 25 " 

Water 1,000 " 

Very strong alcoholic solution. 

Carbolic-acid crystals 10 grams, 

Alcohol 50 " 

Instead of these, I recommend the following solutions, 
which, as I have said before, are preferable, even for the 
spray. 

Strong aqueous solution, red. 

Carbolic-acid crystals .... 50 grams, 

Glycerine 50 " 

Water 1,000 " 

Weak aqueous solution. 

Carbolic-acid crystals .... 25 grams, 

Glycerine 25 " 

Water 1,000 " 

Carbolized oil and glycerine. 

The acid dissolves well in both these substances, and the 
solutions are very manageable. The oil parts with the acid 
which it contains much more slowly than either alcohol or 
water ; and, therefore, before the employment of the gauze, 
it was the carbolized oil which Lister selected for his anti- 
septic agent. 

15 



218 ANTISEPTIC SURGERY. 

Two different strengths of the oil are generally used. 
The first is employed to lubricate catheters, trocars, specula, 
etc., and is composed of 

Carbolic-acid crystals 5 grams, 

Olive oil 100 " 

The second is used in dressings, and contains — 

Carbolic-acid crystals 10 grams, 

Olive oil 100 " 

Certain dressings which require to be frequently renewed 
are made of lint or charpie saturated with this oil. In 
France, in place of lint, we use wadding or compresses im- 
pregnated with it. The dressings often need to be changed 
twice a day. 

I have often applied such an oiled compress to inflamed 
parts in place of a cataplasm, putting a layer of wadding 
above it, and outside of this the impermeable. The patients 
seem to be as much relieved as by a poultice, and do not incur 
the dangers inherent in the dirty epithems. 

Gauze. 

This is made of fine, unbleached tarlatan, washed, to make 
it more pervious, and dried. Pieces five or six meters long 
are folded into squares, heated in a stove, and then treated 
with the following mixture : — 

Carbolic-acid crystals ... 1 part by weight, 

Common resin 5 parts " " 

Paraffin 7 " " " 

The resin and paraffin are to be mixed in a water-bath, and 
the carbolic acid added gradually. 

The mixture is applied by means of a syringe with a large 
nozzle, which is perforated with a number of holes, each 



HOW TO PREPARE GAUZE. 219 

square of the gauze having injected between its folds a quan- 
tity of the liquid about equal to its own weight. Then it is 
returned to the stove for several hours, in order that the 
mixture may be equally diffused ; or the same result may be 
obtained by the action of a press. 

Gauze thus prepared, though light, is flexible and firm, is 
of a yellowish color, and exhales a strong odor of carbolic 
acid. It should be kept in an air-tight canister to protect it 
from heat, which favors its evaporation. In fact, if it is 
warmed even by the heat of the skin, it gradually gives up 
its acid. 

This prepared gauze is the most expensive part of the 
dressing, because so much of it is used ; and yet it was well 
made formerly at the Edinburgh Infirmary for less than six 
cents a meter ; and a dressing for the thigh requires scarcely 
two meters. In Paris one can hardly get it for ten cents a 
meter. However, all the large pieces may be washed after 
they have been used, and then recharged with the resinous 
mixture, thus effecting a considerable saving ; for the great 
cost is in the gauze, and not in the mixture which saturates 
it. 

Roller bandages made of this material are remarkably 
good, being very flexible and strong, and not slipping as 
ordinary bandages do. 

Various other materials have been offered as substitutes 
for the gauze ; but whatever they are, certain indispensable 
properties should be required of them. In the gauze, the 
carbolic acid is the fermenticide. The resin has the prop- 
erty of holding the acid a long time, and letting it escape only 
very slowly. The paraffin is a neutral substance, but it 
imparts desirable consistency, does not change the resin, and 
keeps the gauze from adhering to the skin, an accident 
which would be very vexatious. 



220 ANTISEPTIC SURGERY. 

Protective. 

This material is prepared by coating fine, well-made oil- 
silk with a delicate layer of copal varnish, and applying 
outside of this a pellicle of dextrine. It is not in itself anti- 
septic, but it protects the wound from the irritant action of 
the carbolic acid in the gauze. Simple oil-silk will not pre- 
vent the passage of the acid, as I have found to my sorrow ; 
hence the application of the varnish, which is impermeable to 
it. The dextrine is designed to retain a little of the anti- 
septic solution in which the protective is dipped before being 
placed on the wound. 

So minute a quantity of the protective is required for each 
wound that a little will last a long time, and its cost is not 
worth considering. 

In preparing it we take common oil-silk and cover both 
surfaces with a film of copal varnish. When this is dry, we 
apply with a brush a thin layer of the following mixture : — 

Dextrine 1 parts, 

Powdered starch 2 " 

Cold one-to-fortv solution of carbolic 

acid 16 " 

The last ingredient is used to facilitate the deposition of a 
pellicle of dextrine. 

Mackintosh. 

This is fine and flexible cotton cloth, coated with a deli- 
cate but tough layer of rubber. The flexibility of this mate- 
rial is remarkable, for it will stand any amount of crumpling 
without cracking or breaking, and the impermeable layer 
does not peel at any point. This is an important quality 
from an economic point of view, for it permits the repeated use 



THE MACKINTOSH. 221 

of the mackintosh, and thus saves a very considerable increase 
in the cost of the dressing. After each dressing the pieces 
of this material should be put into soap-suds, and then 
allowed to remain for some hours in the strong solution of car- 
bolic acid. They are then dried, and, at the next dressing, 
just before putting them between the two outer layers of the 
gauze, it is well to carefully moisten both sides with the weak 
solution, in order to destroy the germs which may have been 
deposited upon them. -In this way, two pieces of mackin- 
tosh can be made to answer, as well as more, during the entire 
treatment after an operation, and, indeed, in many different 
cases, thus greatly reducing the estimated cost of the dress- 
ings. The least solution of continuity is a source of danger, 
and every piece of mackintosh which is not perfect should be 
thrown away. 

In Germany they use thin gutta-percha instead of mackin- 
tosh, considering it less expensive. 



Chloride of zinc. 

This substance, being one of the most powerful antiseptics 
known, is of great value. The persistence of its antiseptic 
effect is the peculiar property for which it is especially cele- 
brated, and therefore it is called for in cases where we de- 
sire to purify infected wounds in the most thorough manner. 
The solution which is used in all these cases is the fol- 
lowing : — 

Chloride of zinc 8 grams, 

Water 100 " 

This solution is very caustic, and leaves upon the wound- 
surfaces which it touches a thin eschar, which, however, does 
not hinder union by first intention. Its employment is indi- 



222 ANTISEPTIC SURGEEY. 

cated in wounds which have been exposed for a long time, 
and still more in those cases where complete protection by 
the antiseptic method is impossible. I would recommend it 
in certain cases of cold abscess, where the walls of the cavity 
are too well organized. 

But I would especially call attention to its employment 
where carbolic acid cannot be used for fear of its toxic 
effects. We must then content ourselves with solutions of 
one or two per cent., or even weaker. My experience is not 
sufficiently varied to warrant me in stating the exact limit of 
its antiseptic power. 

Catgut. 

The manufacture of carbolized catgut is so poorly under- 
stood by makers generally that I would advise surgeons to 
make it for themselves, and refer them to what is said on 
this point in the chapter on ligatures. 

To get a solid, aseptic, and sufficiently firm thread, the 
following directions should be exactly observed : — 

Carbolic-acid crystals 20 grams, 

Water 2 " 

Olive oil ......... 100 « 

Pour the water upon the c^stals, and then make an emul- 
sion by vigorously shaking the dissolved acid with the oil. 
Put this into a bottle, in the bottom of which are placed some 
pebbles or glass rods to keep the cord from touching the 
water which settles there. Then place the pieces of gut in 
the bottle, seal it hermetically, and let it stand five or six 
months. The cord is rarely solid before the end of this term, 
and the longer it remains, the better does it become for all 
purposes. ♦ 

A great deal depends upon the original quality of the gut. 



BORACIC ACID. 223 

That which we find in commerce is usually poor stuff. The 
very fine cords are useless, except for some particular sutures. 
The French catgut is the most reliable, and, by the advice of 
a well-known lute-maker, I select the unbleached cords, 
which endure strain the best. I have prepared very large 
cords, quite sufficient to secure the pedicle in ovariotomy. 

Carbolized silk. 

In cases where he does not care to use either catgut or silver 
wire, Lister often has recourse to silk thread. This is pre- 
pared by dipping it into a mixture consisting of two grams of 
pure carbolic acid and sixteen grams of melted wax. The 
thread is then drawn through a cloth, in order to distrib- 
ute the wax evenly over the surface, and to remove the 
excess. 

Boracic acid and its preparations. 

Boracic acid is an excellent antiseptic, but the results ob- 
tained with it as a topical application are comparatively 
mediocre. While it is very unfavorable for the development 
of the phenomena of putrefaction, it does not powerfully 
modify the putrescible substances which are always in excess 
in the vicinity of wounds. Its moderate solubility makes its 
use as a wet topical unsatisfactory. On the other hand, it 
has the advantage of being neither caustic nor irritant. It 
renders very good service in superficial wounds where there 
is no prospect df a considerable discharge ; in the last part of 
the treatment of a wound ; all through the treatment, when 
the injured parts and those in the vicinity are peculiarly liable 
to irritation, as the conjunctiva, for example ; and whenever 
large injections must be made into cavities from which fluids 
return imperfectly or with difficulty. 



224 ANTISEPTIC STJKGERY. 

For all these purposes we use the saturated solution. 
Water at the ordinary temperature will hardly hold four per 
cent, of its weight of the acid. It may, however, be used as 
a dry dressing in the form of 

Boracic lint. 

Taking advantage of the power of boiling water to dissolve 
nearly a third of its weight of boracic acid, we make a very 
valuable preparation. Into boiling water which is saturated 
with boracic acid we dip pieces of lint, that soft and porous 
cotton material which, in the English hospitals, replaces 
charpie. On being dried they are found to have almost 
doubled in weight. In fact, their interstices and surfaces 
are covered with crystals of boracic acid, which are soft and 
not at all injurious to the skin. 

In using boracic lint, we moisten it in a solution of the 
acid, apply it to the wound, and cover it in with the mack- 
intosh. 

Boraeic ointment. 

This is a somewhat unappreciated preparation, but it is 
capable of rendering capital service either as a dressing com- 
plete in itself, when there is little discharge, or in case we 
wish to introduce an unguent into a carbolic dressing. Lis- 
ter gives the following formula : — 

Pure boracic acid ... 1 part by weight, 

White wax 1 " " " 

Paraffin 2 parts " " 

Almond oil 2 " " « 

Mix the wax and paraffin by heating them with the oil ; then 
stir them up thoroughly with powdered boracic acid until 
the mixture thickens. This ointment I have found to be 



PETROLEUM JELLY. 225 

rather hard and not very manageable, and I prefer that which 
is made by the formula below: — 

Oil of sweet almonds 210 grams, 

Paraffin 60 " 

White wax 30 " 

Boracic acid 60 " 

This ointment is spread on fine, soft cotton or linen. It is 
an excellent application to wounds in the vicinity of orifices, 
as about the face, favoring union by first intention, being 
unirritating and a good antiseptic, constantly giving up the 
acid to the liquids which drain away. It is very serviceable 
even in cases where putrefaction cannot be avoided, and one 
can only diminish its effects. 

Vaseline. 

This transparent and unctuous substance, also known as 
petroleum jelly, is a product derived from petroleum, and, 
unlike fats, is absolutely imputrescible. It does not become 
rancid, and for a long time it has been of great service as a 
substitute for the greasy topics, especially in ophthalmic 
surgery. Like glycerine, it dissolves many medicinal sub- 
stances. By triturating it with boracic acid, we get a sort 
of boracic ointment which is a fine antiseptic. 

In his recent work, Nussbaum advises its employment to 
disinfect the hands of the surgeon, and to protect them from 
the irritant action of carbolic acid. He says : " The hands 
of the surgeon who has much operating to do soon become 
rough, often even painful, from the action of the carbolic 
solution. Therefore, I have lately anointed my hands with 
carbolized vaseline made by the following recipe : — 

Carbolic-acid crystals 10 grams, 

Vaseline 90 " 



226 ANTISEPTIC SURGERY. 

This mixture penetrates all the pores and creases, thoroughly 
disinfects the hands, and prevents their becoming rough." 



Jute. 

Good antiseptic preparations may be made of tow impreg- 
nated with antiseptic substances. There are cases in which 
oakum gives excellent results. On account of its cheapness, 
the Germans highly recommend a material which is called 
jute. It is also known as Arracan hemp, and is a tow made 
from the fibre of divers varieties of corchorus, especially the 
corchorus capsularis, cultivated in Bengal, and for a long 
time used in Europe for the manufacture of coarse mats and 
bags. 

Thiersch, who has particularly advised its employment, 
salicylates jute by soaking it in the following solution, and 
then drying it : — 

Salicylic acid . 75 grams, 

Glycerine 500 " 

Water at 80° C 4,500 " 

We may also impregnate the simple jute with the weak 
or the strong solution of carbolic acid, just as we would 
charpie. 

Drainage tubes. 

Being an essential part of the dressing, the drainage tubes 
should always be prepared in advance. We select firm tubes, 
and by preference take the red or black rubber, as they 
are much purer and less easily acquire odors by contact with 
organic matters. They are prepared by fastening a single or 
double thread to one end, and putting them into a wide- 
mouthed bottle filled with strong carbolized water, in which 



OTHER GERMICIDES. 227 

they are kept until needed. The rubber becomes impreg- 
nated with the acid, and the tubes are always ready for use. 

Horsehair is prepared for drains by washing it in an alka- 
line solution to free it from impurities and the greasy matters 
which adhere to it, then doing it up in fasciculi of various 
sizes, and keeping them in a bottle of carbolized water. 

Salicylic and thymic acids. 

These are the chief rivals of carbolic acid ; but, in spite of 
their real value, their employment has always been extremely 
limited. Thiersch, of Leipsic, has been foremost in praise of 
salicylic acid, but his results have been greatly inferior to 
those of surgeons who use the carbolized dressing. 

Salicylic acid is so irritant to the respiratory passages that 
it is impossible to use it for the spray. Even the handling 
of pieces of dressing which are well impregnated with the 
acid is sufficient to annoy the assistants. 

Salicylic acid is so slightly soluble that we must either 
employ very weak aqueous solutions (one part to three 
hundred), or add a considerable quantity of alcohol. 

Thymic acid is very irritant and even less soluble than 
the salicylic. The solutions which are employed have no 
antiseptic value. It is, moreover, very costly — an objection 
of no moderate consequence. 

The antiseptic gauze made with thymol or thymic acid, in 
a manner similar to that employed in making carbolic gauze, 
is used to a very limited extent. It is worthy of note that, 
at the last congress of German surgeons, those who were for- 
merly very enthusiastic admirers of thymic acid declared that 
it had little value, and that they had been obliged to return 
to carbolic acid. This was a result which could easily have 
been predicted. 



228 ANTISEPTIC SURGERY. 

For a long time thymic acid had been used in France, where 
it was known as an antiseptic, but was never extensively em- 
ployed on account of its irritant and caustic qualities, its 
insolubility, and its costliness. 

Salicylic wadding. 
It is proper to state that we can utilize certain prepara- 
tions like salicylic wadding to complete a dressing. This is 
wadding impregnated with salicylic acid, by immersing it in 
a solution of the acid in alcohol and water, and then drying 
it. The quantity of acid in this preparation can be regulated 
by making a stronger or weaker solution. Nussbaum's method 
of making a ten-per-cent. salicylic wadding is as follows : — 

Salicylic acid 1 kilogram, 

Alcohol 1 " 

Water at 80° C ...... 60 liters. 

Dissolve the acid in the alcohol, and add the water. Take 
ten kilograms of wadding which has been cleansed of grease, 
and immerse it in this solution for several hours. Then 
spread it on boards to dry. 

In a similar way salicylic jute is prepared. 

Compound preparations. 
An idea which I consider fruitful is that of combining 
several antiseptics. I have had but little experience in this 
line, but I can point to M. Siredey, who associates thymic 
with carbolic acids. I would also call attention to the pre- 
paration of a Paris apothecary, which is known as the anti- 
septic liquor of Pennes, and contains salicylic and thymic 
acids and the essence of eucalyptus. It is a powerful anti- 
septic. It is quite probable that a judicious combination of 
antiseptics will permit us to reach certain kinds of micro- 
organisms, which are sensitive to a compound antiseptic 
only. 



A USEFUL ANTISEPTIC. 229 



Sulphite of sodium. 

It may be worth while to notice the employment of this 
substance, so highly extolled in Italy. According to the 
confession of Dr. Angelo Minich, who has urged its method- 
ical employment in an important work which was published 
in Venice in 1876, it is inferior to carbolic acid, but it is 
plain that, in some cases, we may make use of a good part of 
the formulae which he gives. He recommends it as cheap, 
unirritant, and as a preventive of even erysipelas. For the 
spray and dressings he uses this solution : — 

Sulphite of sodium 100 grams, 

Glycerine 50 " 

Water 1,000 " 

He makes the dressing by applying a layer of gutta-percha 
upon the wound, strips of simple gauze steeped in the solu- 
tion, a thick layer of purified cotton, and a bandage of gauze 
soaked in the antiseptic solution. He has even replaced the 
wadding with flaxen tow or salicylic hemp. The dressing is 
renewed as is the genuine antiseptic dressing. 

Cataplasms are replaced by compresses saturated with the 
hot solution. 

When the wound begins to cicatrize, the wet dressing is 
no longer favorable, and Minich advises the application of a 
cloth spread with this ointment : — 

Tannate of lead 4 grams, 

Lard 30 " 

Sulphite of sodium 4 " 

Above this is placed a layer of salicylic wadding, and over 
all a thin layer of gutta-percha. 



APPENDIX 



Comparison of Some of the Principal Measures of the Metric System 
with those in Common Use. 



MEASURES OF LENGTH. 



1 Millimeter = 0.03937 inch, or about ^ inch. 
1 Centimeter = 0.3937 inch, or about t 4 q inch. 
1 Meter = 39.37 inches, or about 40 inches. 

1 Kilometer = 0.62137 mile, or about 1100 yards. 



MEASURES OF WEIGHT. 

1 Milligram = 0.0154 grain, or about -^ grain. 

1 Centigram = 0.1543 grain, or about £ grain. 

1 Gram = 15.432 grains, or about 15^ grains. 

1 Kilogram = 2.2046 avoirdupois pounds, or about 2\ pounds. 

MEASURES OF CAPACITY. 

1 Milliliter or cubic centimeter = 

16.2293 minims, or about 16 minims. 
1 Liter = 2.1132 pints (U. S. wine measure), or about 2 pints, 1 
fluid ounce. 



232 



APPENDIX. 



Comparison of Thermometric Scales . 



Centigrade. 


Fahrenheit. 


Centigrade. 


Fahrenheit 


0. 


32. 


40.5 


105. 


10. 


50. 


41. 


105.8 


20. 


68. 


41.1 


106. 


25. 


77. 


41.2 


106.2 


30. 


86. 


41.6 


107. 


35. 


95. 


4*2. 


107.6 


35.5 


96. 


42.2 


108. 


36.1 


97. 


42.5 


108.5 


36.6 


98. 


42.7 


109. 


37. 


98.6 


43. 


109.4 


37.2 


99. 


43.3 


110. 


37.5 


99.5 


43.9 


111. 


37.7 


100. 


44.4 


112. 


38. 


100.4 


50. 


122. 


38.3 


101. 


60. 


140. 


38.7 


101.7 


70. 


158. 


38.9 


102. 


80. 


176. 


39. 


102.2 


90. 


194. 


39.4 


103. 


100. 


212. 


40. 


104. 







INDEX 



acute 180 

cold 182 

congestive 182 

Accouchement 169 

Alcohol, an antiseptic 21 

Amputations 128 

Anaesthetic action of carbolic acid 207 

Antiseptic method, objections to 204 

Antiseptics anciently used 19 

compound 228 

Bone drainage-tubes 71 

Boracic acid 58, 223 

Boracic lint 224 

Boracic ointment 224 

Cesarean section 158 

Callus, resection of vicious 124 

Carbolic acid 214 

an anaesthetic 207 

eczema produced by 203 

irritant action of 208 

poisoning by 200 

solutions of 216 

Carbolized glycerine 217 

Carbolized oil 217 

Carbolized silk 223 

Castration 187 

16 



234 INDEX. 

Catgut 83 

as a ligature 85, 177 

as a suture 87 

for drainage 70 

preparation of 84, 222 

Championniere's spray-producer 77 

Clots, assisting repair 94 

Club-foot 189 

Codman & Shurtleff's spray-producer 81 

Comparison of metric and common measures 230 

of thermometric scales 230 

Compression with sponge 45 

Cost of the dressing 207 

Defence against germs after operation 38 

Destruction of germs before operation 34 

during operation 36 

Disarticulations 130 

Dislocations, operations to relieve 136 

Drainage, conditions of 67 

how affected 40 

tubes 226 

absorbable , 171 

method of using 68 

rubber 67 

with catgut 70 

with horse-hair 71 

Dressing, the 43 

cost of 207 

of old wounds 53 

of wounds near natural orifices 53 

indications for renewal of 47 

time for omission of 60 

Eczema, carbolic 203 

Empyema 185 

Excision of joints 143 

Eye, operations on the 194 



INDEX. 235 

False joints, resection of 126 

Female genitals, surgery of 164 

Fibrous tumors of uterus 168 

Fistula, vesico-vaginal 167 

Foreign bodies, removal of, from joints 134 

Formulae for preparing antiseptic materials 214 

Fractures, compound 119 

ununited 136 

Gastrotomy 163 

Gauze, preparation of 218 

Genitals, surgery of female 164 

Genu valgum 125 

Germs, a cause of suppuration 28 

defence against 38 

destruction of 34, 36 

the cause of putrefaction 25 

Gilbrin's experience 114 

Glycerine, carbolized 217 

Grafting 191 

Guerin's wadded dressing 19 

Gunshot wounds 123 

Hanks's spray-producer 82 

Healthfulness of antiseptic hospitals 197 

Hernia, radical cure of 149 

strangulated 146 

Horse-hair for a drain 71 

Hospitals, influence of Listerism on 197 

Hydatids of liver 163 

Hydrarthrosis 136 

Hydrocele 188 

Inflammation, absence of 95 

Irritation, a cause of suppuration 27 

prevention of 42 

Joints, irrigation of inflamed 141 

opening of diseased 137 



236 INDEX. 

Joints, resection of 143 

wounds of 132 

Jute . 226 

Kelotomy 146 

Laparotomy, for internal strangulation 152 

Larrey's dressings 18 

Lead plates to confine deep sutures 42 

Ligation of vessels 176 

Lint, boracic 224 

Listerism, its influence on hospitalism 197 

the theory of 25 

Lister's experience in Glasgow 105 

spray-producer 76 

Lithotomy, hypogastric 185 

Liver, hydatid cysts of 163 

Mackintosh, preparation of 220 

Metric measures compared with common 231 

Micro-organisms, absence of 102 

Natural orifices, wounds near 56 

Nephrotomy 163 

Nerves, excision of 129 

Objections to antiseptic method . 204 

Obstetric practice 169 

Occlusion dressings 18 

Oil, carbolized 217 

Ointment, boracic 224 

Old wounds, dressing of 53 

Omission of dressing, time for 60 

Oophorectomy 163 

Operations on peritoneum 146 

Ophthalmic surgery 194 

Osteotomy 124 

Ovariotomy 154 



INDEX. 237 

Pain, freedom from 95 

Pasteur's discoveries 23 

Perineorrhaphy 167 

Peritoneum, operations on 146 

Plaster bandage in compound fractures 121 

Plastic operations 115 

Poisoning by carbolic acid 200 

Porro's operation 158 

Practice of the dressing 33 

Preparation of antiseptic materials 214 

Protection of surgeon 198 

Protective, preparation of the 220 

Putrefaction, caused by germs 25 

Rachitic curvatures 125 

Renewal of dressing, indications for 47 

Repair, influence of Listerism on 89 

phenomena of 90 

rapidity of 91 

regularity of 95 

Resection of joints ' . 143 

Results of the dressing 104 

Richardson's spray-producer 75 

Rubber drainage-tubes 67 

Ruptured perineum 167 

Salicylic acid 227 

Salicylic wadding 228 

Saxtorph's experience .107 

Silk, carbolized 223 

Sodium, sulphite of 229 

Solutions of carbolic acid 216 

Sponge, compression with 45 

Spray, the antiseptic 73 

management of 37 

Spray-producer, Championniere's 77 

Codman & Shurtleff's 81 

Hanks's 82 



238 INDEX. 

Spray-producer, Lister's 76 

principles of 75 

Richardson's 75 

Weir's 82 

Strangulation, laparotomy for internal 152 

Substitutes for Lister's method 212 

Suppuration, an obstacle to repair 26 

caused by germs 28 

conditions favorable to 27 

Sutures, deep 63 

materials for 65 

superficial 62 

Talipes 189 

Tendons, operations on 189 

Tension, excessive, a cause of suppuration 27 

prevention of excessive 40 

Theory of Listerism 25 

Thermometric scales, comparison of 232 

Thymic acid 227 

Traumatic fever, cause of 92 

Trephining 190 

Tumors of uterus, fibrous 1 68 

Tumors, removal of 116 

Ulcers 191 

Union by first intention 115 

Ununited fractures 136 

Uterus, fibrous tumors of 168 

Vagina, obliteration of 164 

Varix, radical cure of 178 

Vaseline , . . 225 

Vesico-vaginal fistula 167 

Vessels, ligation of 176 

Volkmann's experience 109 

Wadded dressing of Guerin 19 

Wadding, salicylic 228 



INDEX. 239 

Weir's spray producer 82 

White swellings, opening of 141 

Wound complications, absence of 101 

Wounds near natural orifices 53 

Wounds, dressing of recent ... - 53 

dressing of suppurating 54 

which cannot be closed 59 

Zinc, chloride of 221 



THE END. 



Other Works by Dr. Championniere. 

In French. 

The Uterine Lymphatics and Uterine Lymphangitis. The part played by 
lymphangitis in puerperal complications and uterine diseases. 1870. 

The Lymphatics of the Womb and their role in uterine pathology. 1875. 

Traumatic Fever. 1872. 

Historical and Clinical Study of Trephining of the Skull. 

Journal of Practical Medicine and Surgery. A monthly magazine of forty-eight 
pages. 

Practitioners' Dictionary. A complete and alphabetical index to the first forty 
annual volumes of the Journal of Practical Medicine and Surgery. 



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